See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/360463907

The DSM-5 Level of Personality Functioning Scale

Chapter · May 2023

DOI: 10.1093/med-psych/9780197542521.003.0025

CITATIONS READS

26 3,928

3 authors, including:

Johannes Zimmermann Christopher Hopwood

University of Kassel University of Zurich
281 PUBLICATIONS 9,645 CITATIONS 448 PUBLICATIONS 16,931 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Johannes Zimmermann on 20 July 2022.

The user has requested enhancement of the downloaded file.

 The DSM-5 Level of Personality Functioning Scale

Johannes Zimmermann

University of Kassel, Kassel, Germany

Christopher J. Hopwood

University of Zurich, Zurich, Switzerland

Robert F. Krueger

University of Minnesota, Minnesota, USA

Fourth Draft April 7 2022

Chapter for R. F. Krueger & P. H. Blaney (Eds.), Oxford Textbook of Psychopathology

(4th ed.). Oxford University Press.

Corresponding author: Johannes Zimmermann, Department of Psychology, University

of Kassel. Holländische Str. 36-38, 34127 Kassel, Germany. Tel: +49 561 804-3833, Fax: +49

561 804-3586, E-Mail: [email protected].

Acknowledgements: We thank Bo Bach, Paul Blaney, Kirstin Goth, Benjamin

Hummelen, Joost Hutsebaut, André Kerber, Anne Lehner, Sascha Müller, and Carina

Remmers for helpful feedback on an earlier draft of this chapter.

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 2

Abstract

Dimensional models are becoming increasingly important in the classification of

personality disorders. A central concept of this paradigm shift is the notion of a continuum of

personality functioning ranging from a healthy to an extremely disturbed personality. In the

Alternative Model for Personality Disorders in DSM-5 Section III, this concept corresponds to

Criterion A, which is operationalized by the Level of Personality Functioning Scale (LPFS).

In the first part of this chapter, we explain why and how the LPFS was developed and what

measures are available that are based on its definition. Then we provide an updated

comprehensive summary of research on the LPFS and derived measures, including results on

(a) interrater reliability, (b) internal consistency and latent structure, (c) convergent validity,

(d) discriminant and incremental validity, and (e) clinical utility. Finally, we discuss

controversies and open questions.

Keywords: dimensional model; general factor; personality disorder; personality

functioning; severity
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 3

Personality disorders (PDs) are common in the general population and are associated

with many negative consequences for both the person affected as well as their environment

(Hengartner et al., 2018; Tyrer et al., 2015). The disorder is highly relevant for professionals

from the health care system as it can severely affect the interaction with the patient as well as

the success of medical and therapeutic interventions. A valid classification system is an

indispensable prerequisite for the efficient diagnosis, treatment, and research into the causes

of PD. Current classification systems for PD, such as the one in DSM-5 Section II, list

purportedly distinct disorders; in the case of DSM-5, they are paranoid, schizoid, schizotypal,

antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive

PD. This categorical approach has come under criticism and is likely to be replaced in the

long term by dimensional approaches. A central concept in this paradigm shift is the idea of a

continuum in personality functioning, ranging from healthy to extremely disturbed

personality. This idea of PD severity has been exemplified in Criterion A of the Alternative

Model for Personality Disorders (AMPD) in DSM-5 Section III, which is operationalized by

the Level of Personality Functioning Scale (LPFS). The purpose of this chapter is to explain

why and how the LPFS was developed, what measures are available that are based on its

definition, and what empirical evidence exists on various aspects of the reliability, validity,

and clinical utility of these measures. Additionally, controversies and open questions will be

addressed.

Arguments in favor of taking severity of PD into account

There are a number of arguments in favor of including a severity scale in a

classification system for PD. First, as with the vast majority of mental disorders, underlying

individual differences in PD are continuously distributed and do not consist of two discrete

groups of individuals with and without the disorder (Haslam et al., 2020). For example, the

observed patterns of symptoms of borderline PD (Conway et al., 2012), narcissistic PD

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 4

(Aslinger et al., 2018), and schizotypal PD (Ahmed et al., 2013) are all consistent with a

dimensional rather than a categorical model. Overcoming the relatively arbitrary division into

individuals with and without disorder and exploiting the multiple gradations of severity will

significantly improve the reliability and validity of measurements (Markon et al., 2011). It

will also make it possible to account for the substantial proportion of individuals who exhibit

mild personality problems that are nevertheless associated with diminished functioning

(Karukivi et al., 2017; Thompson et al., 2019; Yang et al., 2010).

Second, it has long been known that PD diagnoses often co-occur, which is usually

referred to as “comorbidity”. For example, in a study of outpatients, it was found that of all

patients who met criteria for PD, approximately 60% met criteria for at least one other PD

(Zimmerman et al., 2005). Indeed, from a factor analytic perspective, there is considerable

evidence for a general PD factor: When all PD diagnoses or criteria are considered together,

they are shown to load not only on specific factors but also on a general factor (Conway et al.,

2016; Hengartner et al., 2014; Paap et al., 2021; Ringwald et al., 2019; Sharp et al., 2015;

Williams et al., 2018). Although the strength of the general factor varies across samples and

assessment methods, it can be concluded that there is indeed a common construct underlying

most of the individual PD criteria. This construct can be interpreted as the general severity of

PD (g-PD), in a similar way as the g-factor of intelligence.

Third, g-PD, in terms of the total number of PD criteria met across all categories, has

been repeatedly shown to be a good predictor of current and future problems in various life

domains (Conway et al., 2016; Hopwood et al., 2011; Williams et al., 2018; Wright et al.,

2016). Although other specific factors related to stylistic aspects or traits usually also

contribute to prediction, g-PD is often the strongest predictor in relative terms. This suggests

that a direct mapping of severity is highly relevant in terms of prognosis. Accordingly,

proposals have now been developed on how to use PD severity to plan therapy (Bach &
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 5

Simonsen, 2021; Hopwood, 2018). While a less-structured and -intensive treatment setting

may be beneficial for a milder severity level (e.g., group therapy), a structured treatment

setting with clear boundaries appears to be necessary for severe impairment and the clinician

must be very intentional about building the relationship, repairing ruptures, and preventing

dropout. In general, due to its prognostic relevance, severity appears to be particularly useful

for determining a patient’s level of care.

Fourth, reanalysis of a longitudinal study of PD demonstrates that g-PD has much less

absolute stability compared to the specific factors (Wright et al., 2016). For example, mean

severity decreased by more than one standard deviation over a ten-year period, whereas scores

on the specific factors (with the exception of compulsivity) changed little on average. This

suggests that general severity captures not only a large part of interindividual differences but

also a large part of intraindividual changes in PD symptoms over time. This is relevant

because change in PD symptoms is often the central endpoint for therapeutic interventions

(e.g., Cristea et al., 2017).

Finally, the introduction of a severity continuum would also improve public

recognition of the modifiable nature of PD and thus hopefully help destigmatize the diagnosis.

For example, Tyrer et al. (2015) expressed the hope that treating experts might then be more

willing to make the diagnosis even in adolescence (to enable early interventions) because it

would in principle be seen as modifiable and not as a lifelong label. This is also in line with a

recent meta-analysis on the relationship between a dimensional understanding of mental

disorders and stigmatization: The more people assume a continuum between mental health

and illness, the less they tend to have stigmatizing attitudes towards people with mental

disorders (Peter et al., 2021).

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 6

Arguments for the central role of impairments in self and interpersonal functioning

If one agrees that a classification system for PD should reflect general severity, the

question arises as to how severity should be operationalized in concrete terms. Various

proposals have been made, some long before the AMPD was developed (Crawford et al.,

2011). For example, severity could simply be determined by the number of categorical PD

diagnoses (Tyrer & Johnson, 1996) or measured separately using the Global Assessment of

Functioning (GAF) scale (Widiger & Trull, 2007) or a list of negative consequences (Leising

& Zimmermann, 2011). The latter options would map how severely a person is impaired in

performing roles and activities of daily living, including social activities, school or work,

recreation or leisure, and basic activities of self-care and mobility.

Opting for a different approach, the DSM-5 Work Group based severity on the degree

of impairment of internal abilities that underlie the perception and regulation of self and

interpersonal relationships (Skodol, 2012). An important reason for this was to provide a

substantive link to the general criteria for PDs, thus ensuring a relatively high degree of

specificity for pathological personality processes (Bender et al., 2011). As the general criteria

for PD introduced in DSM-IV were considered vague and ineffective (Livesley, 1998; Parker

et al., 2002), a major goal of the DSM-5 Work Group was to elaborate on the core substantive

features of personality pathology.

Earlier research had suggested that the features common to all PD relate to problems

of the self (e.g., identity disturbance, low self-direction) and to problems in interpersonal

relationships (e.g., isolation, uncooperativeness, fear of rejection) (Gutiérrez et al., 2008;

Hopwood et al., 2011; Svrakic et al., 1993; Turkheimer et al., 2008). These content domains

also emerged in a factor analysis of several general criteria for PD (Parker et al., 2004). In

recent studies of the factor structure of individual PD criteria, features such as emotional

dysregulation, distorted thoughts about self and others, and problematic interpersonal
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 7

behaviors were also found to exhibit high loadings on the g-PD (Sharp et al., 2015; Williams

et al., 2018). This is especially true for borderline personality disorder (BPD) criteria, which

often did not load on specific factors at all and to that extent can be considered particularly

“pure” markers of g-PD. Based on such findings, some authors have suggested that “it may be

more fruitful to reconceptualize BPD – and particularly the criteria tapping impairment in self

and interpersonal pathology – (...) as reflecting a broad, general dimension of PD-severity

rather than a specific PD category” (Clark et al., 2018). Taken together, there is evidence from

studies with different empirical approaches that problems in the domains of self and

interpersonal relationships are key general indicators of PD.

A further argument for the relevance of these domains comes from an analysis of the

normative assumptions underlying PD diagnoses in DSM-IV (Leising et al., 2009). In this

regard, one must first realize that assigning a PD diagnosis to a person necessarily involves

comparing the person’s personality to an image of how people “normally” should feel or

behave. Leising et al. (2009) addressed this issue by semantically reversing the 79 individual

PD criteria in DSM-IV, resulting in a set of positive expectations regarding desirable behavior.

Cluster analysis of the sorting data revealed ten higher-order clusters of values that cut across

the ten PD categories. Many of these values can be categorized as being related to self-

functioning (e.g., be self-reliant and independent; be self-confident, but in a realistic manner;

have self-control) and to interpersonal functioning (e.g., get along with others; connect with

others emotionally and treat them fairly; enjoy social relationships and activities). It could

thus be argued that the implicit normative assumptions that appear to have guided the

development of the PD criteria in DSM-IV already include the foci of self and interpersonal

relationships.

The relevance of these domains is also emphasized in many major theories of PD,

including psychodynamic (Clarkin et al., 2020; Luyten & Blatt, 2013), interpersonal
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 8

(Hopwood et al., 2013; Pincus et al., 2020), and attachment (Meyer & Pilkonis, 2005) theories

of PD. Another approach that brings this particularly into focus comes from Livesley (1998).

According to his understanding, the core of PD is the failure to develop self and interpersonal

capacities necessary to perform important life tasks. Lastly, such a definition of the general

characteristics of PD also allows Wakefield’s (1992) notion of “dysfunction” to be introduced

into the definition of PD. Accordingly, PD is not merely a pattern of experience and behavior

that is harmful or negative in terms of social values but rather it emerges from an underlying

dysfunction in which a psychological mechanism fails and no longer performs the natural

function for which it was selected in the course of evolution (Krueger et al., 2007).

Development of the DSM-5 Level of Personality Functioning Scale

These and similar considerations have led the DSM-5 Work Group to develop a

revised Criterion A that both requires the presence of significant impairments in self and

interpersonal functioning for a diagnosis of PD and also can be used simultaneously to

determine the severity of impairment (Skodol, 2012). The result of this development process

is the LPFS, which is an operationalization of this new general Criterion A. Originally, it was

envisioned that the revised criteria, including the LPFS, would replace the categorical PDs of

DSM-IV, but in the end it was decided to add them as an alternative model in Section III of

DSM-5.

The DSM-5 Work Group initially took a two-pronged approach. First, data were

reanalyzed on two self-report instruments available at the time that were designed to measure

impaired personality functioning (Morey et al., 2011). The two instruments were the Severity

Indices of Personality Problems (SIPP-118; Verheul et al., 2008) and the General Assessment

of Personality Disorder (GAPD; Livesley, 2006). Item response theory (IRT) models were

used to select items that measured the general factor well at different levels of severity. The

item set was then validated using external data on severity, for example, the presence of a PD
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 9

diagnosis according to structured interviews or the total number of PD criteria met. The

selected items covered the theoretically expected deficits in the domain of the self (e.g.,

identity integration, integrity of self-concept) and interpersonal relationships (e.g., capacity

for empathy and intimacy).

Second, although members of the DSM-5 Work Group emphasized the transtheoretical

background of the LPFS (Bender et al., 2011), psychodynamically oriented models and

measures have been particularly influential in its development (Blüml & Doering, 2021;

Clarkin et al., 2020; Hörz-Sagstetter et al., 2021; Yalch, 2020; Zimmermann et al., 2012). It is

one of the central assumptions of many psychodynamic models that maladaptive mental

representations of self and others form the core of personality pathology and that the degree of

disturbance can be assessed along different levels of functioning (Kernberg, 1984; Luyten &

Blatt, 2013; Westen et al., 2006). Kernberg (1984) proposed, for example, that levels of

personality organization are manifested in three domains of functioning: (a) integration of

one’s identity (i.e., the ability to develop nuanced and stable images of self and others), (b)

maturity of defense mechanisms (i.e., the ability to process threatening internal and external

stimuli in an adaptive manner), and (c) integrity of reality testing (i.e., the ability to

distinguish between internal and external stimuli and make contact with a socially shared

reality). Kernberg also distinguished three levels of severity based on the degree of

impairment in these areas of functioning, namely neurotic, borderline, and psychotic

personality organization. More recent psychodynamic conceptualizations of severity, such as

the Level of Structural Integration Axis of the Operationalized Psychodynamic Diagnosis-2

(OPD Task Force, 2008; Zimmermann et al., 2012) or the Mental Functioning Axis of the

Psychodynamic Diagnostic Manual-2 (PDM-2; Lingiardi & McWilliams, 2017), are similar to

Kernberg’s model in that they refer to impairments in basic psychological capacities and

distinguish between several prototypical levels of functioning.

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 10

Against this background, it is unsurprising that members of the DSM-5 Work Group

encountered only psychodynamically oriented measures in their search for relevant expert

clinical assessment systems (Bender et al., 2011). To justify and streamline the initial LPFS

proposal, the authors established methodological criteria for instruments to be considered in

the broader DSM-5 revision process. The instruments should (a) include important dimensions

of psychological functioning; (b) have a self-other focus; (c) have been used in studies with

general clinical samples, with personality disordered samples, or with both; (d) have concepts

useful to a wide range of clinicians; (e) be appropriate for assessing clinical interview

material; and (f) have published psychometric data on relevant domains of functioning. Using

these criteria, Bender et al. (2011) identified the following five psychodynamically based

instruments: The Quality of Object Relations Scale (QORS; Azim et al., 1991), the

Personality Organization Diagnostic Form (PODF; Gamache et al., 2009), the Object

Relations Inventory (ORI; Blatt et al., 1988), the Social Cognition and Object Relations Scale

(SCORS; Westen et al., 1990), and the Reflective Functioning Scale (RFS; Fonagy et al.,

1998). The final version of the LPFS can thus also be seen as an attempt to integrate existing

psychodynamic rating scales of personality functioning while maximizing reliability and

clinical utility.

In the final stage of development, the diagnostic threshold for the presence of PD was

determined empirically. This was based on a pilot study of the AMPD in which 337 clinicians

each assessed one of their patients using the categorical DSM-IV model and the new AMPD

(Morey et al., 2013). The cut-off score of 2 on the LPFS scale of 0 to 4 achieved a sensitivity

of 84.6% and a specificity of 72.7% in predicting the presence (vs. absence) of at least one

diagnosable PD according to DSM-IV. This level was therefore set as the threshold for the

diagnosis of PD.
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 11

The DSM-5 Level of Personality Functioning Scale

Criterion A is used to determine the presence and severity of PD and can be assessed

using the LPFS. The LPFS defines the severity of PD based on the degree of impairment in

self and interpersonal functioning. This severity continuum is further specified by

psychological characteristics considered typical of different degrees of impairment in the

”components” (DSM-5, p. 772) of identity and self-direction (i.e., self-functioning) and

empathy and intimacy (i.e., interpersonal functioning). Each of the four components is further

broken down into three subcomponents. Intimacy, for example, means that a person (a) can

form deep and lasting relationships with others, (b) wants to and can be close to others, and

(c) treats others with respect. Table 1 summarizes all four components and 12 subcomponents.

Note that despite these fine-grained definitions, all components and subcomponents are

intended to represent a general dimension of PD severity. The LPFS classifies this continuum

into five different “levels” of impairment, beginning with little or no impairment (level 0),

moving through mild (level 1), moderate (level 2), severe (level 3), and ending with extreme

impairment (level 4). With level 0, the description of a healthy personality without

impairments is explicitly provided for the first time in DSM-5. As mentioned above, moderate

impairment (level 2) represents the threshold for the presence of PD.

To facilitate assessment, the LPFS operationalizes all 60 possible combinations of

subcomponents and levels using prototypical descriptions (see the table on pp. 775ff. of DSM-

5). For example, the respective paragraphs for the first subcomponent within self-direction

(i.e., ability to pursue meaningful goals) are: “Sets and aspires to reasonable goals based on a

realistic assessment of personal capacities” (level 0); “Excessively goal-directed, somewhat

goal-inhibited, or conflicted about goals” (level 1); “Goals are more often a means of gaining

external approval than self-generated and thus may lack coherence and/or stability” (level 2);

“Difficulty establishing and/or achieving personal goals” (level 3); and “Poor differentiation
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 12

of thoughts from actions, so goal-setting ability is severely compromised, with unrealistic or

incoherent goals” (level 4). The diagnostician is asked to match these descriptions to the

specific case and indicate on a global five-point scale which level of functioning best

corresponds to the patient’s overall functioning (i.e., across all four components). In other

words, each patient is assigned a single overall score on the LPFS.

Measures based on the DSM-5 Level of Personality Functioning Scale

Central to measuring PD severity in research and practice to date has been the use of

the LPFS itself. Originally, this involved an expert rating on a single five-point scale as

described above (Morey et al., 2013). Other researchers have applied the LPFS in a more

sophisticated way by having the four components (Dereboy et al., 2018; Few et al., 2013), the

12 subcomponents (Cruitt et al., 2019; Hutsebaut et al., 2017; Preti et al., 2018; Roche, 2018;

Zimmermann et al., 2014), or the 60 prototypical descriptions (Zimmermann et al., 2015)

assessed separately and then aggregating the ratings into an overall score. For the purpose of

collecting self-report data, some researchers have asked individuals to self-report according to

prototypical descriptions of the 12 subcomponents (Bliton et al., 2021; Dowgwillo et al.,

2018; Roche et al., 2016; Roche et al., 2018). For the purpose of informant reports, it has been

suggested that the 60 prototypical descriptions of the LPFS can also be individually assessed

by laypersons (Morey, 2018; Zimmermann et al., 2015).

Following the publication of DSM-5, new measurement instruments have been

developed to implement the operationalization of severity according to the LPFS (Birkhölzer

et al., 2020; Zimmermann et al., 2019). These measures are summarized in Table 2, including

references to validated translations. On the one hand, structured clinical interviews are

available to systematically collect information relevant to applying the LPFS. For example,

the Structured Clinical Interview for the Level of Personality Functioning Scale (SCID-

AMPD Module I; Bender, Skodol, et al., 2018) has a funnel structure, starting with open-
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 13

ended questions for each subcomponent to get an initial impression of severity, and then

going in-depth according to that impression with specific follow-up questions for the assumed

level. The Semi-Structured Interview for Personality Functioning DSM–5 (STiP-5.1;

Hutsebaut et al., 2017) has a similar funnel structure and can also be used on adolescents

(Weekers, Verhoeff, et al., 2021).

On the other hand, several self-reports are available that build on the understanding of

PD severity according to LPFS but use items that are easier for lay people to understand.

These measures differ in number of items and differentiation into subscales. For example, the

Level of Personality Functioning Scale – Brief Form (LPFS-BF; Hutsebaut et al., 2016;

updated version LPFS-BF 2.0; Weekers et al., 2019) comprises only 12 items in total, with

each item describing impairment in one subcomponent. The evaluation refers to the two

subscales of impairments in self and interpersonal functioning as well as to an overall score.

Because of its efficiency and compatibility with ICD-11 (see below), the LPFS-BF 2.0 has

recently been proposed to be used as part of a standard battery for patient-reported outcomes

in PD (Prevolnik Rupel et al., 2021). In contrast, the Level of Personality Functioning Scale –

Self-Report (LPFS-SR; Morey, 2017) comprises 80 items, each describing different levels of

severity from all 12 subcomponents. Items are aggregated on a weighted basis according to

severity, yielding four scales for impairments in the components of identity, self-direction,

empathy, and intimacy, as well as a total score. Finally, one self-report measure, the Levels of

Personality Functioning Questionnaire for Adolescents from 12 to 18 Years (LoPF-Q 12-18;

Goth et al., 2018), was directly tailored to the target population of adolescents.

Further developments to measure severity according to LPFS include items that can be

used in the context of intensive longitudinal designs. In this way, fluctuations and nuanced

temporal dynamics in the components of identity, self-direction, empathy, and intimacy can

be revealed (Roche et al., 2016; Roche, 2018). In addition, impairment scales have been
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 14

developed to examine the validity of impairment criteria for the six specific PDs listed under

the rubric of Criterion A in the AMPD (Anderson & Sellbom, 2018; Liggett et al., 2017;

Liggett & Sellbom, 2018; McCabe & Widiger, 2020). What is not yet available but could be

useful in higher-risk clinical settings are indices that indicate negligent or biased responses.

Psychometric properties and empirical findings pertaining to the LPFS

Numerous reviews have summarized the theoretical underpinnings and current

research findings on personality functioning in the AMPD (Bach & Simonsen, 2021; Bender,

Zimmermann, & Huprich, 2018; Clark et al., 2018; Herpertz et al., 2017; Hörz-Sagstetter et

al., 2021; Morey & Bender, 2021; Pincus, 2018; Pincus et al., 2020; Sharp & Wall, 2021;

Sinnaeve et al., 2021; Sleep et al., 2021; Widiger et al., 2019; Zimmermann et al., 2019;

Hopwood et al., in press). We provide below an updated comprehensive summary of research

on the LPFS. We include only studies that applied the LPFS or one of the measures listed in

Table 2, ensuring high specificity for AMPD definitions of severity. Results are organized

according to the questions of (a) interrater reliability, (b) internal consistency and latent

structure, (c) convergent validity, (d) discriminant and incremental validity, and (e) clinical

utility.

Interrater reliability

Interrater reliability refers to agreement between judges of the same individual’s level

of personality functioning. Table 3 summarizes the studies that have examined the interrater

reliability of the LPFS. Results suggest that interrater reliability is largely acceptable when

using the LPFS based on case vignettes (Garcia et al., 2018; Morey, 2019), written life history

data (Roche et al., 2018), personality or life story interviews (Cruitt et al., 2019; Roche &

Jaweed, 2021), clinical interviews (Di Pierro et al., 2020; Few et al., 2013; Preti et al., 2018;

Zimmermann et al., 2014), or unstructured clinical impressions (Dereboy et al., 2018), even

among untrained and clinically inexperienced raters. Across these ten studies including 676
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 15

targets and 3,451 ratings, the weighted intraclass correlation coefficient (ICC) for the LPFS

total score was .55, 95% CI [.47, .63]. However, training can increase interrater reliability

(Garcia et al., 2018), and interrater reliability is usually significantly better when based on

structured interviews that are explicitly tailored to collect the required information. Nine

studies on such interviews have been conducted so far, including 276 targets and 662 ratings

(Buer Christensen et al., 2018; Hutsebaut et al., 2017; Kampe et al., 2018; Meisner et al.,

2021; Møller et al., 2021; Ohse et al., 2021; Somma et al., 2020; Thylstrup et al., 2016; Zettl

et al., 2020). The weighted ICC for the LPFS total score across these studies was .83, 95% CI

[.75, .92], which is considered excellent (Cicchetti, 1994). An exception is the CALF, where

interrater reliability was at the lower limit, presumably because the interview does not probe

closely enough the behaviors and experiences described in the LPFS and requires a higher

degree of inference (Thylstrup et al., 2016). For the SCID-AMPD Module I, two studies are

now available that use a more-rigorous test-retest design in which patients are re-interviewed

by a different person within a short period of time. Here, the ICC for the LPFS total score was

.75 (Buer Christensen et al., 2018) and .84 (Ohse et al., 2021), respectively.

Internal Consistency and Latent Structure

Internal consistency refers to the question of whether ratings of different aspects of a

person’s personality functioning result in similar test scores. In other words: The question is

whether individual differences in these aspects are positively correlated and thus “consistent”

and can be aggregated into a single construct. This can be considered at different levels in the

LPFS and the derived self-report measures: For example, one can investigate whether the

LPFS total score is internally consistent when looking at the ratings on the four components,

or whether an LPFS-SR score regarding the component empathy is internally consistent when

looking at the ratings on the individual items. The results here are generally positive: For

example, the internal consistency of the overall LPFS score has been shown to be acceptable
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 16

when calculated based on ratings of the four components (Dereboy et al., 2018; Morey et al.,

2013), and as very high when calculated based on scores of subcomponents (Bach &

Hutsebaut, 2018; Cruitt et al., 2019; Dowgwillo et al., 2018; Hutsebaut et al., 2017) or

individual items (Hopwood et al., 2018; Morey, 2017, 2018). Scores on the four components

(Cruitt et al., 2019; Hopwood et al., 2018; Huprich et al., 2018; Morey, 2017, 2018;

Zimmermann et al., 2014) and the 12 subcomponents (Zimmermann et al., 2015) also

achieved fairly high internal consistency.

However, from the perspective of psychometric models such as IRT or factor analyses,

high internal consistency is not sufficient to justify the formation of an overall score. It is also

required to test the fit of a measurement model according to which the different ratings can be

explained by an underlying latent variable. The first comprehensive analysis of the latent

structure of LPFS was conducted by Zimmermann et al. (2015). Data were collected through

an online study in which 515 laypersons and 145 therapists rated all 60 prototypical

descriptions of the LPFS. Laypersons were asked to rate one of their personal acquaintances,

whereas therapists were asked to rate one of their patients. The results on latent structure were

broadly consistent with the assumptions of the LPFS, although there were some discrepancies.

First, it was possible to demonstrate, using so-called “unfolding” IRT models (Roberts et al.,

2000; see below), that most subcomponents are indeed unidimensional. This means that the

ratings on the five prototypical descriptions of a subcomponent (e.g., ability to pursue

meaningful goals, see above) can be explained by a single underlying latent dimension. There

were however exceptions such as the second subcomponent within intimacy (i.e., desire and

capacity for closeness), where the pattern of associations between ratings turned out to be

more complex. This could be due to the fact that the individual descriptions from this

subcomponent emphasize quite different signs and explanations of impaired capacity for
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 17

closeness (e.g., inhibition in level 1, self-regulation needs in level 2, and rejection sensitivity

in level 3), suggesting that the underlying construct is rather multidimensional.

Second, using Exploratory Structural Equation Modeling, it was shown that the

structure of the 12 subcomponents was largely consistent with a model that included two

strongly correlated factors of self and interpersonal functioning. There were some

discrepancies here as well: For example, there was not much support for the theoretical

differentiation of self functioning into identity and self-direction on the one hand and

interpersonal functioning into empathy and intimacy on the other. Crucially, however, the

high correlation of the two factors of self and interpersonal functioning is consistent with a

model that assumes a strong general factor for the 12 subcomponents. Indeed, the proportion

of variance in the LPFS total score that could be attributed to the general factor was .78,

suggesting that while individuals may differ to some extent in their specific type of

impairment (i.e., whether their personality problems are more related to self or interpersonal

functioning), the main source of differences is related to the general severity of impairments.

Thus, although forming an overall score may be difficult in some cases because impairment in

self and interpersonal functioning differs too much, the use of a single score for the LPFS

appears to be broadly acceptable in clinical practice.

Meanwhile, these findings on the latent structure of the subcomponents of the LPFS

have been widely confirmed in other studies. Support for a model with two strongly correlated

factors of self and interpersonal functioning has emerged in studies involving both self-reports

based on the items of the LPFS (Bliton et al., 2021; Roche, 2018), the LPFS-BF (Bach &

Hutsebaut, 2018; Bliton et al., 2021; Hutsebaut et al., 2016; Spitzer et al., 2021; Weekers et

al., 2019) and the PFS (Stover et al., 2020) as well as in expert ratings based on the SCID-

AMPD Module I (Hummelen et al., 2021; Ohse et al., 2021) or STiP-5.1 (Heissler et al.,

2021). Although this may challenge the theoretical distinction into four components, it is
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 18

consistent with the assumption of a strong general factor representing PD severity. Evidence

for such a factor is also found in confirmatory factor analyses of SIPS items (Gamache et al.,

2019) and principal component analyses of the four components of LPFS-SR (Hopwood et

al., 2018; Morey, 2017) and LPFS (Cruitt et al., 2019). Item-level factor analyses of the

LPFS-SR often deviate more from the theoretical structure or achieve poor model fit (Bliton

et al., 2021; Hemmati et al., 2020; Sleep et al., 2019; Sleep et al., 2020). This is at least partly

due to the sheer size of the model (which can lead to biased fit statistics; Moshagen, 2012), as

well as to method factors due to items with positive and negative valence. In any case, a

strong general factor is also apparent in item-level analyses of the LPFS and LPFS-SR, which

may justify the use of the overall score (Bliton et al., 2021; Leising et al., 2021). Interestingly,

these analyses also indicated that loadings on the general factor were almost perfectly

predictable from the social desirability of the items (Leising et al., 2021). This suggests that

the impairments in personality functioning as defined by the LPFS and derivate measures are

essentially guided by a social consensus of negatively valued experiences and behaviors.

Two other aspects of the LPFS are particularly challenging in the study of their latent

structure – aspects that seem less relevant for constructs such as personality traits. First, the

LPFS involves not only a differentiation into different components and subcomponents, but

also into different levels that are supposed to represent different degrees of severity. The

question, then, is whether the five individual descriptions of a given subcomponent are

arranged in a theoretically consistent manner along the latent severity continuum. For

example, the descriptions “Excessively goal-directed, somewhat goal-inhibited, or conflicted

about goals” (level 1) and “Goals are more often a means of gaining external approval than

self-generated and thus may lack coherence and/or stability” (level 2) should be located at

different points on the latent severity continuum (i.e., the latter description should reflect a

significantly higher severity level than the former description). In the study with informant
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 19

ratings by Zimmermann et al. (2015), this assumption was tested using unfolding IRT models.

In unfolding IRT models, a location parameter is estimated for each item, indicating where

individuals are located on the latent dimension when they are most likely to agree with the

item (Roberts et al., 2000). It was found that the relationship between the theoretically

hypothesized severity levels and the empirically estimated location parameters was quite

strong across all items. This largely supports the classification of the LPFS descriptions and

confirms the results from surveys in which the items of the LPFS were directly assessed with

respect to different severity concepts as well as social (un)desirability (Leising et al., 2018;

Zimmermann et al., 2012). On the other hand, several location parameters emerged that

deviated somewhat from this general pattern. For example, location parameters of the items

for moderate, severe, and extreme impairment in subcomponents of identity (i.e., sense of self,

self-esteem and accurate self-perception) and self-direction (i.e., self-reflective functioning)

were all uniformly at the dysfunctional pole of the latent continuum, suggesting that, on

average, raters did not capture the subtle differences in severity that the descriptions were

intended to convey. Further studies are needed here to refine the LPFS descriptions

accordingly, if necessary.

Second, strictly speaking, the AMPD does not mention clearly delineable factors in

Criterion A, but rather “components” or “elements” that are described as “reciprocally

influential and inextricably tied” (DSM-5, p. 772). This assumption is consistent with the high

internal consistency of LPFS ratings, as interpenetrating elements should lead to strong

positive correlations. However, the question arises whether factor analyses targeting relative

stable differences between persons are sufficient or even appropriate to investigate such an

assumption. Here, it would probably be useful to work with longitudinal studies to look at the

reciprocal interrelationships of these elements within individuals over time, that is, to model

the internal structure of personality functioning as a developmental process. To date, there is

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 20

only one study using a 12-item version of the LPFS on a daily basis over 14 days that found

clear evidence for a unidimensional latent structure at the within-person level (Roche, 2018).

Studies that span longer time periods and test reciprocal, time-lagged effects between

components do not yet exist.

Convergent validity

Convergent validity concerns the question of whether ratings of personality

functioning are highly correlated with other measures of the same or similar constructs. The

most obvious test for this is to assess personality functioning according to the LPFS with two

different measures and to determine their correlation. Here, substantial correlations have been

shown in the vast majority of studies to date, both between LPFS expert or informant ratings

and self-report measures (Heissler et al., 2021; Nelson et al., 2018; Ohse et al., 2021; Roche et

al., 2018; Roche & Jaweed, 2021; Somma et al., 2020; Weekers, Verhoeff, et al., 2021) as

well as between different self-report measures (Bliton et al., 2021; McCabe et al., 2021a;

Roche & Jaweed, 2021; Somma et al., 2020). An exception with null findings is a study with

forensic patients, although here the sample was very small (Hutsebaut et al., 2021).

Substantial associations with numerous measures of similar constructs were found for

other-reports of the LPFS. These studies are summarized in the left column of Table 4. For

example, strong associations were found with established measures of impairments in

personality functioning and PD severity, including number of PD diagnoses according to

DSM-IV or psychodynamic conceptualizations of personality dysfunction. Additionally,

studies have examined associations with more-distant constructs and indicators that do not

directly support convergent validity of the LPFS as an expert rating but highlight its scientific

and clinical relevance. These include associations with short-term risk, proposed treatment

intensity, and estimated prognosis (Morey et al., 2013), prior treatment for mental health

problems (Cruitt et al., 2019), as well as risk of dropping out of residential treatment
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 21

(Busmann et al., 2019). There are also studies linking LPFS ratings to biological parameters,

such as intralimbic resting-state functional connectivity (Traynor et al., 2021). By contrast, no

associations emerged with various measures of narrative coherence measured in life-story

interviews (Dimitrova & Simms, 2021).

Initial validation studies of self-report measures based on LPFS also indicated

substantial convergence with established measures of impairments in personality functioning

and PD severity as well as with a number of constructs from the clinical literature (see right

column of Table 4). Additionally, from the perspective of basic research in personality

psychology, it is relevant that self-report measures assessing personality functioning generally

exhibit a profile of correlations with Big Five personality traits that is typical for PDs in

general (Saulsman & Page, 2004). This profile consists of negative correlations with

emotional stability, conscientiousness, extraversion, and agreeableness, among which the

negative correlation with emotional stability is usually the strongest (Hopwood et al., 2018;

McCabe et al., 2021a; Oltmanns & Widiger, 2019; Sleep et al., 2020; Stone et al., 2020;

Stricker & Pietrowsky, 2021). However, for informant reports, these correlations are

sometimes extremely high (e.g., observed associations with low emotional stability and

agreeableness approached .80; Morey, 2018), which corresponds to an overall less-

differentiated personality description among informants (Beer & Watson, 2008). Also

conceptually relevant are findings that impairment scores on self-report measures of

personality functioning decrease with age in representative samples from the general

population (Spitzer et al., 2021). This is consistent with theories and findings on the

maturation of personality over the lifespan (Bleidorn et al., 2013). Finally, there are also

initial studies exploring the correlates of impairments in personality functioning with

intensive longitudinal designs in everyday life. For example, results across studies showed

that individuals experience more negative affect and less positive affect in everyday life as
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 22

self-reported impairment increases (Heiland & Veilleux, 2021; Ringwald et al., 2021; Roche,

2018). Additionally, individuals with high levels of personality dysfunction also reported

corresponding problems in everyday life (Roche et al., 2016; Roche et al., 2018), experienced

less affiliative and dominant behaviors and perceived less affiliation in others (Ringwald et

al., 2021), and experienced more intense stressors and more invalidation by others (Heiland &

Veilleux, 2021). One study found an indication that high levels of personality dysfunction are

generally associated with more instability in experience and behavior (Ringwald et al., 2021),

although this was not confirmed in another study (Roche et al., 2016).

Discriminant and incremental validity

Discriminant validity refers to the question of whether ratings of personality

functioning differ sufficiently from measurements that refer to other constructs. This aspect of

validity is not so easy to assess. On the one hand, of course, some variables do not correlate

with personality functioning. For example, associations between the LPFS-BF total score and

gender were found to be approximately zero in representative samples (Spitzer et al., 2021),

suggesting that different levels of severity are distributed independent of the gender of the

person. On the other hand, numerous studies listed in Table 4 show that other-reports of

LPFS, as well as corresponding self-report measures, are indeed substantially correlated with

measures of a wide variety of other clinical constructs. Such correlations can make sense from

a theoretical perspective: For example, it could be that impairments in personality functioning

and in physical health correlate because they share common causes or influence each other. In

some cases, it is also the case that the other constructs are nothing more than subsets of

personality functioning and to that extent overlap in their definitions (e.g., low self-esteem,

impaired mentalization). Against this background, it becomes clear that it often makes little

sense to expect low correlations with measures of other clinical constructs.

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 23

However, what might be an important test of discriminant validity from the

perspective of the developers of the LPFS is to examine whether the LPFS ratings are specific

to PD. This kind of question can be addressed in two ways: by ascertaining whether LPFS

ratings are more pronounced in patients with traditional PD diagnoses than in both healthy

controls and patients with other diagnoses, and by ascertaining whether LPFS ratings correlate

more strongly with the number of PD criteria fulfilled than with nonspecific symptomatic

burden. There are now a few studies that have demonstrated specificity for PD for expert-

based LPFS ratings (Di Pierro et al., 2020; Heissler et al., 2021; Hutsebaut et al., 2017; Ohse

et al., 2021). However, this pattern is less clear for self-report measures, as correlations with

various symptom measures related to other mental disorders such as depression or anxiety are

often only slightly lower (Sleep et al., 2019; Sleep et al., 2020), or even equal (Spitzer et al.,

2021) to correlations with PD measures. A similar conclusion was reached in a study by

McCabe et al. (2021b), in which a general factor of PD (g-PD) defined using the LPFS-SR

and DLOPFQ total scores, among other measures, was correlated with a broadly defined

general factor of psychopathology (“p factor”). The authors found a latent correlation of .94,

suggesting that, at least in self-reports, there is little specificity of the LPFS for PD. Put

another way: The relevant self-report measures arguably capture impairments that are relevant

to all mental disorders.

Incremental validity addresses the question of whether ratings of personality

functioning provide additional information for predicting various clinically relevant

experiences and behaviors, that is, information that is not included in other measures. The

question of the specificity of the LPFS for PD can also be formulated from the perspective of

incremental validity: Here, it would then be necessary to examine whether LPFS ratings

predict the presence and severity of PD when controlling statistically for nonspecific

symptom burden or comorbid mental disorders. This has indeed been shown for other-reports
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 24

of the LPFS (Preti et al., 2018; Zimmermann et al., 2014). Other important application

scenarios for testing incremental validity include whether LPFS measures contain additional

information relative to categorical PD diagnoses or general personality traits. For example,

Morey et al. (2013) demonstrated that expert ratings of LPFS predicted psychosocial

functioning, short-term risk, proposed treatment intensity, and estimated prognosis when

categorical PD diagnoses were statistically controlled. This was confirmed by Buer

Christensen et al. (2020) with respect to self-reported and clinician-rated psychosocial

functioning. In addition, one study suggests that the LPFS total score predicts several specific

PDs according to DSM-IV as well as health- and relationship-related indicators when

controlling for general personality traits (Cruitt et al., 2019). Incremental validity over general

personality traits in predicting specific PDs according to DSM-IV was also confirmed for the

LPFS-SR as a self-report measure (Sleep et al., 2020).

Clinical utility

A classification system for PD must be not only valid but also clinically useful in

order to be applied in practice. Clinical utility is a complex concept that, when understood

very broadly, also includes aspects of validity (e.g., meaningful conceptualization of the

disorder and mapping of prognostically relevant information; First et al., 2004; Keeley et al.,

2016). More narrowly, this refers to how easily the system can be used in practice by

clinicians, to what extent it facilitates communication between different stakeholders (e.g.,

between different clinicians or between clinicians and patients or relatives), and also to what

extent it supports clinicians’ treatment planning (Mullins-Sweatt & Widiger, 2009). Such

aspects have already been illustrated for the AMPD with numerous case reports (Bach et al.,

2015; Pincus et al., 2016; Schmeck et al., 2013; Skodol et al., 2015; Weekers et al., 2020) and

summarized in reviews (Bach & Tracy, 2021; Hopwood, 2018; Milinkovic & Tiliopoulos,

2020).
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 25

An important method for exploring clinical utility is to conduct consumer surveys

which ask clinicians directly about aspects of a diagnostic system’s utility after having used

the system on case vignettes or real patients. Bornstein and Natoli (2019) conducted a meta-

analysis of such studies, two of which also referenced the AMPD (Morey et al., 2014; Nelson

et al., 2017). In the meta-analysis, dimensional approaches were found to be more useful than

categorical diagnosis in DSM-IV or DSM-5 Section II in terms of communicating with the

patient, formulating a therapeutic intervention, and describing the specific problems and

overall personality of the patient. The study by Morey et al. (2014), which builds on

assessments of utility from 337 clinicians and also allows specific statements about the LPFS

as a severity rating based on a single item, seems particularly relevant. Here, the LPFS was

found to be more difficult to apply and less useful in terms of communication with colleagues,

but at least on par with DSM-IV PD diagnoses in terms of the other aspects of clinical utility.

Psychologists (but not psychiatrists) even perceived advantages with the LPFS over DSM-IV

PDs. Positive evaluations were also obtained when asking students about clinical utility after

they applied the LPFS to multiple case vignettes (Garcia et al., 2018).

A qualitative study of the learnability and usefulness of the SCID-AMPD Module I

with Norwegian clinicians concluded that this interview was more likely to meet clinicians’

interests and needs than categorical diagnostic interviews (Heltne et al., 2021). For example, it

was mentioned positively that the SCID-AMPD Module I provides dimensional assessments

and focuses on important topics not explicitly asked elsewhere, thereby helping patients to

feel seen and understood. At the same time, certain challenges and limitations were identified,

including high requirements for theoretical knowledge and some interview questions that

were difficult to understand or could be experienced as confrontational. The authors also

recommended the development of more specific guidelines for training.

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 26

Additionally, there are other areas and methodological approaches to clinical utility

that have not yet been explored for the LPFS. For example, Weekers, Hutsebaut, and

Kamphuis (2021) have indicated that consideration of patient strengths – largely missing from

traditional diagnostic systems – is a welcome aspect in terms of clinical utility. In this regard,

the explicit description of a healthy personality in level 0 of the LPFS could be an advantage.

It was also emphasized that patients themselves should be involved in the process of utility

assessment. Here, complementary domains include, in particular, the extent to which the

diagnosis is associated with less stigma (e.g., is respectful of the whole person and promotes

self-acceptance) and is conducted collaboratively (Weekers, Hutsebaut, & Kamphuis, 2021).

From a methodological perspective, it is also important to consider that consumer surveys are

insufficient to demonstrate that a particular form of assessment actually improves clinical care

(Kamphuis et al., 2021; Lewis et al., 2019). Future studies should therefore both examine

aspects of client utility of the LPFS and employ stronger designs such as randomized clinical

trials to demonstrate the utility of the LPFS for treatment.

Controversies, questions, and next steps

Relationship to maladaptive personality traits (Criterion B)

In the AMPD, in addition to Criterion A, there is also a Criterion B, which is used to

determine the individual expression of PD (Freilich et al., in press). To this end, a hierarchical

model of maladaptive personality traits was developed based on empirical analyses (Krueger

et al., 2012). At a higher level, the model includes five broad trait domains: Negative

affectivity, detachment, antagonism, disinhibition, and psychoticism. At a lower level, these

domains are further specified by 25 trait facets. Disinhibition, for example, is subdivided into

(a) irresponsibility, (b) impulsivity, (c) distractibility, (d) risk-taking, and (e) low rigid

perfectionism. For a diagnosis of PD, in addition to moderate impairments in personality

functioning, at least one maladaptive personality trait or facet must be clinically significant.
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 27

One controversy regarding the AMPD is whether impairments in personality

functioning (Criterion A) and maladaptive personality traits (Criterion B) provide redundant

information (for conceptual discussions, see Bender, 2019; Bornstein, 2019; Leising et al.,

2018; Meehan et al., 2019; Sharp & Wall, 2021; Sleep et al., 2021; Widiger et al., 2019).

From a semantic perspective, Criterion A and B share a focus on describing socially

undesirable features (Leising et al., 2018), and differences appear to be primarily due to

theoretical traditions and the level of inference (Mulay et al., 2018). From an empirical

perspective, there is also strong evidence that measures of Criterion A and Criterion B are

highly correlated and to that extent discriminant validity tends to be low (Bach & Anderson,

2020; Bach & Hutsebaut, 2018; Few et al., 2013; Gamache et al., 2019; Garcia et al., 2021;

Hopwood et al., 2018; Huprich et al., 2018; McCabe & Widiger, 2020; Nelson et al., 2018;

Ohse et al., 2021; Roche et al., 2018; Roche & Jaweed, 2021; Sleep et al., 2019; Sleep et al.,

2020; Stover et al., 2020). Moreover, previous findings regarding incremental validity have

been mixed and can be interpreted in various ways. On the one hand, there are numerous

studies demonstrating incremental validity of severity ratings compared to maladaptive traits,

for example, in predicting PDs according to DSM-IV (Cruitt et al., 2019; Sleep et al., 2019;

Sleep et al., 2020; Wygant et al., 2016), personality dynamics in daily life (Ringwald et al.,

2021; Roche et al., 2016; Roche, 2018), symptom distress (Bach & Hutsebaut, 2018; Roche &

Jaweed, 2021), substance use and physical health (Cruitt et al., 2019), well-being (Bach &

Hutsebaut, 2018; Huprich et al., 2018), maladaptive schemas (Bach & Hutsebaut, 2018),

interpersonal dependence (Huprich et al., 2018), and physical violence (Leclerc et al., 2021).

On the other hand, the effect sizes are, though statistically significant, often small, and some

studies have found no incremental value for severity ratings in predicting PDs according to

DSM-IV (e.g., Few et al., 2013).

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 28

Exemplary of these complex findings is the study on informant ratings by

Zimmermann et al. (2015) described above. In this study, the 25 trait facets of Criterion B

were analyzed together with the 12 subcomponents of Criterion A using exploratory structural

equation modeling. A total of seven factors emerged, with two factors roughly mapping

impairments in self and interpersonal functioning from Criterion A and another five factors

mapping largely maladaptive traits from Criterion B. However, there were also deviations

from the theoretical mapping in the AMPD: For example, impairments in self-functioning

showed specific associations with the trait facets depressiveness and separation anxiety;

impairments in interpersonal functioning showed specific associations with the trait facets

grandiosity and callousness; and detachment showed specific associations with impairments

in the personality functioning subcomponent depth and duration of connections. In later self-

report studies, a similar differential pattern of association was found, whereby components of

self-functioning correlated particularly strong with facets of negative affectivity and

components of interpersonal functioning correlated particularly strong with facets of

antagonism (e.g., Sleep et al., 2019; Sleep et al., 2020). An important implication of these

findings is that the classification of some content under the rubric of Criterion A or B seems

somewhat arbitrary, or at least cannot be justified on the basis of the pattern of empirical

covariation. For example, the Criterion B facet depressiveness could also be understood as a

specific impairment of the self, and the Criterion A subcomponent depth and duration of

connections could be reinterpreted as an indicator of detachment.

The implications of these findings for a future revision of the classification system are

controversial. A more conservative conclusion would be that the two criteria reflect the same

phenomena from two different clinical perspectives and traditions, both of which are

clinically useful and justified. However, there are also critical perspectives that find the lack

of parsimony problematic: While some scholars argue that Criterion A can be dropped due to
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 29

its low incremental validity (Sleep et al., 2019), other scholars suggest replacing the

pathological personality traits of Criterion B with normal personality traits (e.g., the Big Five)

to better capture the stylistic expression of personality regardless of the severity of the

disorder (Leising & Zimmermann, 2011; Morey et al., 2020).

In our view, the results at least underscore the need for a clearer conceptual

justification of how and why the phenomena currently described in Criteria A and B should be

distinguished from one another and how they relate to one another. For example, if

maladaptive traits are viewed as behaviorally anchored expressions of underlying

impairments in basic internal capacities (e.g., Sharp & Wall, 2021), some degree of

substantive overlap might be warranted, as Criterion A would essentially serve as an

explanation for Criterion B (e.g., a person tends to behave callously because his or her

capacity for empathy is impaired; Zimmermann et al., 2015). However, other authors prefer

conceptualizations that work the other way around, for example, by understanding

dysfunctions as negative consequences or characteristic maladaptations of basic personality

dispositions (cf. Clark & Ro, 2014; Leising & Zimmermann, 2011; Widiger & Mullins-

Sweatt, 2009). These conceptual issues form the core of our understanding of personality

pathology and have crucial implications for the selection of assessment methods. They are

unlikely to be resolved completely with empirical studies and require conceptual clarity and

argumentative precision.

Relationship to severity in ICD-11

Meanwhile, a new model for the classification of PD in ICD-11 has also been finalized

and will come into effect in 2022 (Reed et al., 2019). This model follows the AMPD in some

key respects: For example, the general features of PD are again identified in terms of long-

standing problems in self and interpersonal functioning, a primary classification of severity is

made, ranging from subthreshold personality difficulties to mild and moderate to severe PD,
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 30

and salient personality traits can be specified, including negative affectivity, detachment,

dissociality, disinhibition, anankastia, and a borderline pattern (Bach & First, 2018; Mulder &

Tyrer, 2019). Specifically related to the determination of severity, a high degree of

substantive agreement with the LPFS can be observed: For example, severity in the ICD-11

model is determined based on the extent and pervasiveness of dysfunction of the self (e.g.,

identity, self-esteem, accuracy of self-view, self-direction) and relationships (e.g., interest in

relationships, perspective-taking, intimacy, conflict resolution).

There are however also a few minor differences: First, the extent, pervasiveness, and

chronicity of additional maladaptive experiences and behaviors are to be considered, such as

emotion perception and expression, accuracy of situational appraisals, decision-making ability

under uncertainty, impulse control, and stress resistance. While some of these aspects are also

considered in the LPFS (e.g., impairments in the experience and expression of emotions are

understood as a subcomponent of identity in the LPFS), others are not explicitly listed there

(e.g., stress resistance). Second, the ICD-11 model explicitly considers the degree to which

these characteristics are associated with distress or impairment in different domains of life.

Thus, in a sense, severity in the ICD-11 model is defined both in terms of impairments of

internal abilities related to the self and interpersonal relationships and in terms of negative

psychosocial consequences in everyday life. Finally, in the descriptions of the different

severity levels of PD, the aspect of harm to self and others plays a greater role than in LPFS.

Research on the severity of PD according to ICD-11 is still in its infancy. Most studies

to date on this topic have been based either on reanalysis of archival data (e.g., Tyrer et al.,

2014) or on instruments or rating systems that were based on a preliminary version of the

ICD-11 model (e.g., Kim et al., 2014; Olajide et al., 2018). One example is the Standardized

Assessment of Severity of Personality Disorder (SASPD; Olajide et al., 2018), which should

be understood as an index of PD complexity (in terms of exhibiting traits from different PD

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 31

trait domains) rather than a unidimensional scale of functional impairment. In fact, there are

currently only two studies in which severity has been assessed according to the final ICD-11

definition using new self-report measures (Bach et al., 2021; Clark et al., 2021). For the 14-

item Personality Disorder Severity ICD-11 (PDS-ICD-11; Bach et al., 2021) scale, there was

a correlation of .68 with the total LPFS-BF score in a sample from the general population.

When accounting for the influence of measurement error pushing this estimate downward,

this initial result suggests that severity measures based on AMPD and ICD-11 are highly

overlapping in self-report and may be nearly impossible to differentiate. For a more definite

evaluation of the conceptual and empirical similarities and differences of the two systems

with respect to severity, further studies, preferably using multiple measures and methods, will

be required.

Further development of assessment methods

As noted above, the inclusion of Criterion A in the AMPD has led to the development

of several new self-report measures (see Table 2). Additionally, there are numerous other self-

report instruments on personality functioning that have been developed previously (e.g.,

SIPP-118, GADP), that are aligned with the ICD-11 model for PD (e.g., SASPD, PDS-ICD-

11), or that are based on psychodynamic concepts (e.g., OPD Structure Questionnaire;

Ehrenthal et al., 2012). Although this is a comfortable situation that expands the choices

available to researchers and practitioners, it has the disadvantage of an increasing lack of

standardization. The new measures differ in a number of ways (e.g., underlying theoretical

conceptualizations, emphasis on different aspects of the construct, length, precision, etc.), and

one of the main challenges is that data obtained with different measures are difficult to

compare. Despite their semantic similarities (Waugh et al., 2021) and their usually high

intercorrelations, it is not clear whether these measures assess the same construct and how the

scores obtained from them can be compared.

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 32

One possibility is to use IRT to calibrate different measures against a common metric.

Zimmermann et al. (2020) followed such an approach in a sample from the general

population. A common IRT model was estimated based on data from six widely used self-

report measures or their short forms to link item responses to an underlying general factor.

Measures based on Criterion A of the AMPD (i.e., LPFS-SR and LPFS-BF 2.0) were used, as

well as a measure of Criterion B and measures based on psychodynamic concepts and on an

early version of the ICD-11 model (i.e., SASPD). The results suggest that all measures

capture a strong common factor and can therefore be scaled along a single latent continuum.

The common factor was largely defined by impairments in self and interpersonal functioning,

with a slight predominance of internalizing personality pathology (e.g., anxiety, low self-

esteem). This suggests that the severity of PD based on psychodynamic concepts, Criterion A

and Criterion B of the AMPD, and the ICD-11 are largely consistent when implemented in a

self-report format.

In order to be able to use the measures for the assessment of individual cases in routine

practice, the development of norm values is crucial. The common metric study described

above provides preliminary norms for each of the six measures based on the German general

population (Zimmermann et al., 2020). For individual cases, practitioners can use the Web

platform (http://www.common-metrics.org/) to estimate T scores including 95% confidence

intervals. In this way, an individual’s general severity of PD can be interpreted as a deviation

from the average case and measurement error can be explicitly accounted for. However, it is

important to note that in this study, as in most other studies on the development of norm

values, the representativeness of the sample could only be established to a limited extent (e.g.,

only with respect to age and gender). Other aspects such as education, regional origin, and use

of medical and psychotherapeutic treatments may be biased, especially in online samples

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 33

compared to the general population, which is why norm values from high-quality recruited

random samples may differ significantly (Spitzer et al., 2021).

In addition to the development of norm values, there is also the possibility of

empirically establishing thresholds based on external criteria. DSM-IV PD diagnoses in cross-

sectional data have been mainly used for this purpose so far (e.g., Buer Christensen,

Hummelen, et al., 2020; Gamache, Savard, Leclerc, et al., 2021). Indeed, as noted above,

DSM-IV PD diagnoses were used in the development of the threshold of level 2 on the LPFS

itself (Morey et al., 2013). This approach is understandable insofar as it ensures continuity

with previous categorical systems. However, in light of the criticism of the arbitrary

thresholds of the categorical system, there is also something circular about this approach. In

our view, it would be desirable to use longitudinal studies to calibrate multiple cut-off values

for severity based on the likelihood of future critical life outcomes and adverse consequences.

In addition to integrating and standardizing self-report measures, we should also be

concerned with developing and optimizing other assessment methods. For example, the very

high interrater reliability of LPFS ratings based on structured interviews such as SCID-AMPD

Module I (see Table 3), as well as the sometimes very high agreement with self-reports, can

be viewed critically. The very high interrater reliability is probably also due to the funnel

structure of the interview, through which an outside person can easily guess the implicitly

associated rating based on the interviewer’s jumping to certain interview sections. The high

degree of agreement with the self-report may also be due to the fact that some of the questions

are very direct and the answers thus largely reflect the self-presentation of the interviewee. In

this respect, further research should be conducted to determine the extent to which more open-

ended interview strategies, as in CALF, are associated with lower interrater reliability but may

have greater incremental validity in predicting clinically relevant outcomes compared to self-

report. Finally, it would also be useful to give greater consideration to the possibility and
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 34

appropriateness of maximal-effort tests to capture personality functioning. If one takes

seriously the understanding of Criterion A in terms of impairments in internal mental

capacities (Sharp & Wall, 2021), the development of a test battery to measure performance on

tasks requiring self and interpersonal skills would be the logical next step (e.g., Jauk &

Ehrenthal, 2021; Leising et al., 2011; Olderbak & Wilhelm, 2020).

Conclusion

With the introduction of a severity scale for PD in the AMPD, several criticisms of the

current categorical classification system for PD have been successfully addressed. A severity

scale better captures the dimensional nature of individual differences in impairment, better

accounts for empirical findings of high comorbidity and the substantial general factor in PD

diagnoses, allows more efficient determination of prognosis and change, and contributes to

destigmatization of the diagnosis. In particular, the LPFS as a concrete operationalization of

severity ensures reference to the common denominator of all PDs in Criterion A, and the

focus on impairments in the domain of self and interpersonal relationships builds on both

empirical and conceptual arguments. Since the official publication of the AMPD in 2013,

researchers have begun to explore the reliability, validity, and utility of the LPFS and derived

measures. Results from numerous empirical studies are now available and are generally

promising: Interrater reliability is good for structured interviews, subcomponent ratings can

be modeled by two highly correlated factors of impairments in self and interpersonal

functioning (which is compatible with the assumption of a strong general factor), ratings

correlate highly with measures of similar severity measures in PD, there is evidence of

incremental validity over categorical PD diagnoses, and clinical utility is mostly viewed

positively by practitioners. At the same time, the issue of discriminant validity against

nonspecific distress or other mental disorders, as well as against Criterion B, continues to be

controversial and may also require conceptual clarifications or adaptations of the LPFS. For
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 35

future empirical research, it is particularly desirable to move beyond the widely used

monomethod studies that dominate the literature to date (Zimmermann et al., 2019). This

includes the joint assessment of multiple constructs by multiple methods, allowing for the

investigation of construct-level associations while controlling for shared method variance

(e.g., multitrait-multimethod designs; Campbell & Fiske, 1959). Additionally, intervention

studies should be conducted that focus on severity as a predictor, moderator, and endpoint of

treatment effects. Currently, there is only one study showing that the LPFS-BF 2.0 can be

used as an outcome measure in a three-month residential treatment program (Weekers et al.,

2019). In any case, with the prioritization of severity in the ICD-11 model for PD, there is no

doubt that the DSM-5 LPFS and its derived measurement tools will continue to have an

important place in PD diagnosis and research.

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 36

References

Ahmed, A. O., Green, B. A., Goodrum, N. M., Doane, N. J., Birgenheir, D., & Buckley, P. F.

(2013). Does a latent class underlie schizotypal personality disorder? Implications for

schizophrenia. Journal of Abnormal Psychology, 122(2), 475–491.

https://doi.org/10.1037/a0032713

Anderson, J. L., & Sellbom, M. (2018). Evaluating the DSM-5 Section III personality

disorder impairment criteria. Personality Disorders: Theory, Research, and Treatment,

9(1), 51–61. https://doi.org/10.1037/per0000217

Aslinger, E. N., Manuck, S. B., Pilkonis, P. A., Simms, L. J., & Wright, A. G. C. (2018).

Narcissist or narcissistic? Evaluation of the latent structure of narcissistic personality

disorder. Journal of Abnormal Psychology, 127(5), 496–502.

https://doi.org/10.1037/abn0000363

Azim, H. F., Piper, W. E., Segal, P. M., Nixon, G. W., & Duncan, S. C. (1991). The Quality

of Object Relations Scale. Bulletin of the Menninger Clinic, 55(3), 323–343.

Bach, B., & Anderson, J. L. (2020). Patient-reported ICD-11 personality disorder severity and

DSM-5 level of personality functioning. Journal of Personality Disorders, 34(2), 231–249.

https://doi.org/10.1521/pedi_2018_32_393

Bach, B., Brown, T. A., Mulder, R. T., Newton-Howes, G., Simonsen, E., & Sellbom, M.

(2021). Development and initial evaluation of the ICD-11 personality disorder severity

scale: Pds-ICD-11. Personality and Mental Health, 15(3), 223–236.

https://doi.org/10.1002/pmh.1510

Bach, B., & First, M. B. (2018). Application of the ICD-11 classification of personality

disorders. BMC Psychiatry, 18(1), 351. https://doi.org/10.1186/s12888-018-1908-3

Bach, B., & Hutsebaut, J. (2018). Level of Personality Functioning Scale-Brief Form 2.0:

Utility in capturing personality problems in psychiatric outpatients and incarcerated

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 37

addicts. Journal of Personality Assessment, 100(6), 660–670.

https://doi.org/10.1080/00223891.2018.1428984

Bach, B., Markon, K., Simonsen, E., & Krueger, R. F. (2015). Clinical utility of the DSM-5

Alternative Model of Personality Disorders: Six cases from practice. Journal of Psychiatric

Practice, 21(1), 3–25. https://doi.org/10.1097/01.pra.0000460618.02805.ef

Bach, B., & Simonsen, S. (2021). How does level of personality functioning inform clinical

management and treatment? Implications for ICD-11 classification of personality disorder

severity. Current Opinion in Psychiatry, 34(1), 54–63.

https://doi.org/10.1097/YCO.0000000000000658

Bach, B., & Tracy, M. (2021). Clinical utility of the AMPD: A 10th year anniversary review.

Personality Disorders: Theory, Research, and Treatment. Advance online publication.

https://doi.org/10.1037/per0000527

Back, S. N., Zettl, M., Bertsch, K., & Taubner, S. (2020). Persönlichkeitsfunktionsniveau,

maladaptive Traits und Kindheitstraumata [Personality functioning, maladaptive traits, and

childhood trauma]. Psychotherapeut, 65(5), 374–382. https://doi.org/10.1007/s00278-020-

00445-7

Beer, A., & Watson, D. (2008). Asymmetry in judgments of personality: Others are less

differentiated than the self. Journal of Personality, 76(3), 535–560.

https://doi.org/10.1111/j.1467-6494.2008.00495.x

Bender, D. S. (2019). The p-factor and what it means to be human: Commentary on Criterion

A of the AMPD in HiTOP. Journal of Personality Assessment, 101(4), 356–359.

https://doi.org/10.1080/00223891.2018.1492928

Bender, D. S., Morey, L. C., & Skodol, A. E. (2011). Toward a model for assessing level of

personality functioning in DSM–5, Part I: A review of theory and methods. Journal of

Personality Assessment, 93(4), 332–346. https://doi.org/10.1080/00223891.2011.583808

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 38

Bender, D. S., Skodol, A. E., First, M. B., & Oldham, J. M. (2018). Module I: Structured

Clinical Interview for the Level of Personality Functioning Scale. In M. B. First, A. E.

Skodol, D. S. Bender, & J. M. Oldham (Eds.), Structured Clinical Interview for the DSM-5

Alternative Model for Personality Disorders (SCID-AMPD). American Psychiatric

Association Publishing.

Bender, D. S., Zimmermann, J., & Huprich, S. K. (2018). Introduction to the Special Series

on the personality functioning component of the Alternative DSM-5 Model for Personality

Disorders. Journal of Personality Assessment, 100(6), 565–570.

https://doi.org/10.1080/00223891.2018.1491856

Biberdzic, M., Tang, J., & Tan, J. (2021). Beyond difficulties in self-regulation: The role of

identity integration and personality functioning in young women with disordered eating

behaviours. Journal of Eating Disorders, 9(1), 93. https://doi.org/10.1186/s40337-021-

00398-5

Birkhölzer, M., Schmeck, K., & Goth, K. (2020). Assessment of Criterion A. Current

Opinion in Psychology, 37, 98–103. https://doi.org/10.1016/j.copsyc.2020.09.009

Blatt, S. J., Chevron, E. S., Quinlan, D. M., Schaffer, C. E., & Wein, S. (1988). The

assessment of qualitative and structural dimensions of object representations: Unpublished

research manual. Yale University.

Bleidorn, W., Klimstra, T. A., Denissen, J. J. A., Rentfrow, P. J., Potter, J., & Gosling, S. D.

(2013). Personality maturation around the world: A cross-cultural examination of social-

investment theory. Psychological Science, 24(12), 2530–2540.

https://doi.org/10.1177/0956797613498396

Bliton, C. F., Roche, M. J., Pincus, A. L., & Dueber, D. (2021). Examining the structure and

validity of self-report measures of DSM-5 Alternative Model for Personality Disorders

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 39

Criterion A. Journal of Personality Disorders. Advance online publication.

https://doi.org/10.1521/pedi_2021_35_531

Blüml, V., & Doering, S. (2021). Icd-11 personality disorders: A psychodynamic perspective

on personality functioning. Frontiers in Psychiatry, 12, 654026.

https://doi.org/10.3389/fpsyt.2021.654026

Bornstein, R. F. (2019). From structure to process: On the integration of AMPD and HiTOP.

Journal of Personality Assessment, 101(4), 360–366.

https://doi.org/10.1080/00223891.2018.1501696

Bornstein, R. F., & Natoli, A. P. (2019). Clinical utility of categorical and dimensional

perspectives on personality pathology: A meta-analytic review. Personality Disorders:

Theory, Research, and Treatment, 10(6), 479–490. https://doi.org/10.1037/per0000365

Brown, T. A., & Sellbom, M. (2020). Further validation of the MMPI-2-RF personality

disorder spectra scales. Journal of Psychopathology and Behavioral Assessment, 42(2),

259–270. https://doi.org/10.1007/s10862-020-09789-5

Buer Christensen, T., Eikenaes, I., Hummelen, B., Pedersen, G., Nysæter, T.‑E.,

Bender, D. S., Skodol, A. E., & Selvik, S. G. (2020). Level of personality functioning as a

predictor of psychosocial functioning-Concurrent validity of criterion A. Personality

Disorders: Theory, Research, and Treatment, 11(2), 79–90.

https://doi.org/10.1037/per0000352

Buer Christensen, T., Hummelen, B., Paap, M. C. S., Eikenaes, I., Selvik, S. G., Kvarstein, E.,

Pedersen, G., Bender, D. S., Skodol, A. E., & Nysæter, T. E. (2020). Evaluation of

diagnostic thresholds for Criterion A in the Alternative DSM-5 Model for Personality

Disorders. Journal of Personality Disorders, 34(Supplement C), 40–61.

https://doi.org/10.1521/pedi_2019_33_455
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 40

Buer Christensen, T., Paap, M. C. S., Arnesen, M., Koritzinsky, K., Nysaeter, T.‑E.,

Eikenaes, I., Germans Selvik, S., Walther, K., Torgersen, S., Bender, D. S., Skodol, A. E.,

Kvarstein, E., Pedersen, G., & Hummelen, B. (2018). Interrater reliability of the Structured

Clinical Interview for the DSM-5 Alternative Model of Personality Disorders Module I:

Level of Personality Functioning Scale. Journal of Personality Assessment, 100(6), 630–

641. https://doi.org/10.1080/00223891.2018.1483377

Busmann, M., Wrege, J., Meyer, A. H., Ritzler, F., Schmidlin, M., Lang, U. E., Gaab, J.,

Walter, M., & Euler, S. (2019). Alternative Model of Personality Disorders (DSM-5)

predicts dropout in inpatient psychotherapy for patients with personality disorder.

Frontiers in Psychology, 10, 735. https://doi.org/10.3389/fpsyg.2019.00952

Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation by the

multitrait-multimethod matrix. Psychological Bulletin, 56(2), 81–105.

https://doi.org/10.1037/h0046016

Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and

standardized assessment instruments in psychology. Psychological Assessment, 6(4), 284–

290. https://doi.org/10.1037/1040-3590.6.4.284

Clark, L. A., Corona-Espinosa, A., Khoo, S., Kotelnikova, Y., Levin-Aspenson, H. F.,

Serapio-García, G., & Watson, D. (2021). Preliminary scales for ICD-11 personality

disorder: Self and interpersonal dysfunction plus five personality disorder trait domains.

Frontiers in Psychology, 12, 668724. https://doi.org/10.3389/fpsyg.2021.668724

Clark, L. A., Nuzum, H., & Ro, E. (2018). Manifestations of personality impairment severity:

Comorbidity, course/prognosis, psychosocial dysfunction, and ‘borderline’ personality

features. Current Opinion in Psychology, 21, 117–121.

https://doi.org/10.1016/j.copsyc.2017.12.004
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 41

Clark, L. A., & Ro, E. (2014). Three-pronged assessment and diagnosis of personality

disorder and its consequences: Personality functioning, pathological traits, and

psychosocial disability. Personality Disorders: Theory, Research, and Treatment, 5(1),

55–69. https://doi.org/10.1037/per0000063

Clarkin, J. F., Caligor, E., & Sowislo, J. F. (2020). An object relations model perspective on

the Alternative Model for Personality Disorders (DSM-5). Psychopathology, 53(3-4), 141–

148. https://doi.org/10.1159/000508353

Conway, C. C., Hammen, C., & Brennan, P. (2012). A comparison of latent class, latent trait,

and factor mixture models of DSM-IV borderline personality disorder criteria in a

community setting: Implications for DSM-5. Journal of Personality Disorders, 26(5), 793–

803. https://doi.org/10.1521/pedi.2012.26.5.793

Conway, C. C., Hammen, C., & Brennan, P. (2016). Optimizing prediction of psychosocial

and clinical outcomes with a transdiagnostic model of personality disorder. Journal of

Personality Disorders, 30(4), 545–566. https://doi.org/10.1521/pedi_2015_29_218

Cosgun, S., Goth, K., & Cakiroglu, S. (2021). Levels of Personality Functioning

Questionnaire (LoPF-Q) 12–18 Turkish Version: Reliability, validity, factor structure and

relationship with comorbid psychopathology in a Turkish adolescent sample. Journal of

Psychopathology and Behavioral Assessment, 43(3), 620–631.

https://doi.org/10.1007/s10862-021-09867-2

Crawford, M. J., Koldobsky, N., Mulder, R. T., & Tyrer, P. (2011). Classifying personality

disorder according to severity. Journal of Personality Disorders, 25(3), 321–330.

https://doi.org/10.1521/pedi.2011.25.3.321

Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017).

Efficacy of psychotherapies for borderline personality disorder: A systematic review and

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 42

meta-analysis. JAMA Psychiatry, 74(4), 319–328.

https://doi.org/10.1001/jamapsychiatry.2016.4287

Cruitt, P. J., Boudreaux, M. J., King, H. R., Oltmanns, J. R., & Oltmanns, T. F. (2019).

Examining Criterion A: Dsm-5 level of personality functioning as assessed through life

story interviews. Personality Disorders: Theory, Research, and Treatment, 10(3), 224–

234. https://doi.org/10.1037/per0000321

Dereboy, F., Dereboy, Ç., & Eskin, M. (2018). Validation of the DSM-5 Alternative Model

Personality Disorder diagnoses in Turkey, Part 1: Lead validity and reliability of the

personality functioning ratings. Journal of Personality Assessment, 100(6), 603–611.

https://doi.org/10.1080/00223891.2018.1423989

Di Pierro, R., Gargiulo, I., Poggi, A., Madeddu, F., & Preti, E. (2020). The Level of

Personality Functioning Scale applied to clinical material from the Structured Interview of

Personality Organization (STIPO): Utility in detecting personality pathology. Journal of

Personality Disorders, 34(Supplement C), 62–76.

https://doi.org/10.1521/pedi_2020_34_472

Dimitrova, J., & Simms, L. J. (2021). Construct validation of narrative coherence: Exploring

links with personality functioning and psychopathology. Personality Disorders: Theory,

Research, and Treatment. Advance online publication. https://doi.org/10.1037/per0000508

Dowgwillo, E. A., Roche, M. J., & Pincus, A. L. (2018). Examining the interpersonal nature

of Criterion A of the DSM-5 Section III Alternative Model for Personality Disorders using

bootstrapped confidence intervals for the interpersonal circumplex. Journal of Personality

Assessment, 100(6), 581–592. https://doi.org/10.1080/00223891.2018.1464016

Ehrenthal, J., Dinger, U., Horsch, L., Komo-Lang, M., Klinkerfuß, M., Grande, T., &

Schauenburg, H. (2012). Der OPD-Strukturfragebogen (OPD-SF): Erste Ergebnisse zu

Reliabilität und Validität [The OPD Structure Questionnaire (OPD-SQ): First results on
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 43

reliability and validity]. Psychotherapie, Psychosomatik, Medizinische Psychologie,

62(01), 25–32. https://doi.org/10.1055/s-0031-1295481

Few, L. R., Miller, J. D., Rothbaum, A. O., Meller, S., Maples, J., Terry, D. P., Collins, B., &

MacKillop, J. (2013). Examination of the Section III DSM-5 diagnostic system for

personality disorders in an outpatient clinical sample. Journal of Abnormal Psychology,

122(4), 1057–1069. https://doi.org/10.1037/a0034878

First, M. B., Pincus, H. A., Levine, J. B., Williams, J. B. W., Ustun, B., & Peele, R. (2004).

Clinical utility as a criterion for revising psychiatric diagnoses. American Journal of

Psychiatry, 161(6), 946–954. https://doi.org/10.1176/appi.ajp.161.6.946

Fleck, L., Fuchs, A., Moehler, E., Parzer, P., Koenig, J., Resch, F., & Kaess, M. (2021).

Maternal bonding impairment predicts personality disorder features in adolescence: The

moderating role of child temperament and sex. Personality Disorders: Theory, Research,

and Treatment. Advance online publication. https://doi.org/10.1037/per0000433

Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning manual,

version 5.0, for application to adult attachment interviews. University College London.

Freilich, C. D., Krueger, R. F., Hobbs, K. A., Hopwood, C. J., & Zimmermann, J. (in press).

The DSM-5 maladaptive trait model for personality disorders. In R. F. Krueger & P. H.

Blaney (Eds.), Oxford Textbook of Psychopathology (4th ed.). Oxford University Press.

Gamache, D., Laverdière, O., Diguer, L., Hébert, É., Larochelle, S., & Descôteaux, J. (2009).

The Personality Organization Diagnostic Form. Journal of Nervous and Mental Disease,

197(5), 368–377. https://doi.org/10.1097/NMD.0b013e3181a20897

Gamache, D., Savard, C., Leclerc, P., & Côté, A. (2019). Introducing a short self-report for

the assessment of DSM-5 level of personality functioning for personality disorders: The

Self and Interpersonal Functioning Scale. Personality Disorders: Theory, Research, and

Treatment, 10(5), 438–447. https://doi.org/10.1037/per0000335

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 44

Gamache, D., Savard, C., Leclerc, P., Payant, M., Berthelot, N., Côté, A., Faucher, J.,

Lampron, M., Lemieux, R., Mayrand, K., Nolin, M.‑C., & Tremblay, M. (2021). A

proposed classification of ICD-11 severity degrees of personality pathology using the self

and interpersonal functioning scale. Frontiers in Psychiatry, 12, 628057.

https://doi.org/10.3389/fpsyt.2021.628057

Gamache, D., Savard, C., Lemieux, R., & Berthelot, N. (2021). Impact of level of personality

pathology on affective, behavioral, and thought problems in pregnant women during the

coronavirus disease 2019 pandemic. Personality Disorders: Theory, Research, and

Treatment. Advance online publication. https://doi.org/10.1037/per0000479

Gander, M., Buchheim, A., Bock, A., Steppan, M., Sevecke, K., & Goth, K. (2020).

Unresolved attachment mediates the relationship between childhood trauma and impaired

personality functioning in adolescence. Journal of Personality Disorders, 34(Suppl B), 84–

103. https://doi.org/10.1521/pedi_2020_34_468

Garcia, D. J., Skadberg, R. M., Schmidt, M., Bierma, S., Shorter, R. L., & Waugh, M. H.

(2018). It’s not that difficult: An interrater reliability study of the DSM-5 Section III

Alternative Model for Personality Disorders. Journal of Personality Assessment, 100(6),

612–620. https://doi.org/10.1080/00223891.2018.1428982

Garcia, D. J., Waugh, M. H., Skadberg, R. M., Crittenden, E. B., Finn, M. T. M.,

Schmidt, M. R., & Kurdziel-Adams, G. (2021). Deconstructing Criterion A of the

Alternative Model for Personality Disorders. Personality Disorders: Theory, Research,

and Treatment, 12(4), 320–330. https://doi.org/10.1037/per0000431

Goth, K., Birkhölzer, M., & Schmeck, K. (2018). Assessment of personality functioning in

adolescents with the LoPF-Q 12-18 Self-Report Questionnaire. Journal of Personality

Assessment, 100(6), 680–690. https://doi.org/10.1080/00223891.2018.1489258

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 45

Gutiérrez, F., Navinés, R., Navarro, P., García-Esteve, L., Subirá, S., Torrens, M., & Martín-

Santos, R. (2008). What do all personality disorders have in common? Ineffectiveness and

uncooperativeness. Comprehensive Psychiatry, 49(6), 570–578.

https://doi.org/10.1016/j.comppsych.2008.04.007

Haslam, N., McGrath, M. J., Viechtbauer, W., & Kuppens, P. (2020). Dimensions over

categories: A meta-analysis of taxometric research. Psychological Medicine, 50(9), 1418–

1432. https://doi.org/10.1017/S003329172000183X

Heiland, A. M., & Veilleux, J. C. (2021). Severity of personality dysfunction predicts affect

and self-efficacy in daily life. Personality Disorders: Theory, Research, and Treatment.

Advance online publication. https://doi.org/10.1037/per0000470

Heissler, R., Doubková, N., Hutsebaut, J., & Preiss, M. (2021). Semi-structured interview for

personality functioning DSM-5 (STiP-5.1): Psychometric evaluation of the Czech version.

Personality and Mental Health, 15(3), 198–207. https://doi.org/10.1002/pmh.1508

Heltne, A., Bode, C., Hummelen, B., Falkum, E., Selvik, S. G., & Paap, M. C. S. (2021).

Norwegian clinicians’ experiences of learnability and usability of SCID-II, SCID-5-PD

and SCID-5-AMPD-I interviews: A sequential multi-group qualitative approach. Journal

of Personality Assessment. Advance online publication.

https://doi.org/10.1080/00223891.2021.1975726

Hemmati, A., Morey, L. C., McCredie, M. N., Rezaei, F., Nazari, A., & Rahmani, F. (2020).

Validation of the Persian translation of the Level of Personality Functioning Scale—Self-

Report (LPFS-SR): Comparison of college students and patients with personality disorders.

Journal of Psychopathology and Behavioral Assessment, 42(3), 546–559.

https://doi.org/10.1007/s10862-019-09775-6

Hengartner, M. P., Ajdacic-Gross, V., Rodgers, S., Muller, M., & Rossler, W. (2014). The

joint structure of normal and pathological personality: further evidence for a dimensional
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 46

model. Comprehensive Psychiatry, 55(3), 667–674.

https://doi.org/10.1016/j.comppsych.2013.10.011

Hengartner, M. P., Zimmermann, J., & Wright, A. G. C. (2018). Personality pathology. In V.

Zeigler-Hill & T. Shackelford (Eds.), The SAGE handbook of personality and individual

differences: Volume III: Applications of personality and individual differences (pp. 3–35).

Sage.

Herpertz, S. C., Bertsch, K., & Jeung, H. (2017). Neurobiology of Criterion A: Self and

interpersonal personality functioning. Current Opinion in Psychology, 21, 23–27.

https://doi.org/10.1016/j.copsyc.2017.08.032

Hopwood, C. J. (2018). A framework for treating DSM-5 alternative model for personality

disorder features. Personality and Mental Health, 12(2), 107–125.

https://doi.org/10.1002/pmh.1414

Hopwood, C. J., Fox, S., Bender, D. S., & Zimmermann, J. (in press). The core self/other

dimension of personality functioning. In J. Mihura (Ed.), The Oxford Handbook of

Personality and Psychopathology Assessment (2nd ed.).

https://doi.org/10.1093/oxfordhb/9780190092689.013.5

Hopwood, C. J., Good, E. W., & Morey, L. C. (2018). Validity of the DSM-5 Levels of

Personality Functioning Scale-Self Report. Journal of Personality Assessment, 100(6),

650–659. https://doi.org/10.1080/00223891.2017.1420660

Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow, C. A., Grilo, C. M.,

McGlashan, T. H., Pinto, A., Markowitz, J. C., Shea, M. T., Skodol, A. E.,

Gunderson, J. G., Zanarini, M. C., & Morey, L. C. (2011). Personality assessment in DSM-

5: Empirical support for rating severity, style, and traits. Journal of Personality Disorders,

25(3), 305–320. https://doi.org/10.1521/pedi.2011.25.3.305

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 47

Hopwood, C. J., Wright, A. G. C., Ansell, E. B., & Pincus, A. L. (2013). The interpersonal

core of personality pathology. Journal of Personality Disorders, 27(3), 270–295.

https://doi.org/10.1521/pedi.2013.27.3.270

Hörz-Sagstetter, S., Ohse, L., & Kampe, L. (2021). Three dimensional approaches to

personality disorders: A review on personality functioning, personality structure, and

personality organization. Current Psychiatry Reports, 23(7), 45.

https://doi.org/10.1007/s11920-021-01250-y

Hummelen, B., Braeken, J., Buer Christensen, T., Nysaeter, T. E., Germans Selvik, S.,

Walther, K., Pedersen, G., Eikenaes, I., & Paap, M. C. S. (2021). A psychometric analysis

of the Structured Clinical Interview for the DSM-5 Alternative Model for Personality

Disorders Module I (SCID-5-AMPD-I): Level of Personality Functioning Scale.

Assessment, 28(5), 1320–1333. https://doi.org/10.1177/1073191120967972

Huprich, S. K., Nelson, S. M., Meehan, K. B., Siefert, C. J., Haggerty, G., Sexton, J.,

Dauphin, V. B., Macaluso, M., Jackson, J., Zackula, R., & Baade, L. (2018). Introduction

of the DSM-5 Levels of Personality Functioning Questionnaire. Personality Disorders:

Theory, Research, and Treatment, 9(6), 553–563. https://doi.org/10.1037/per0000264

Hutsebaut, J., Feenstra, D. J., & Kamphuis, J. H. (2016). Development and preliminary

psychometric evaluation of a brief self-report questionnaire for the assessment of the

DSM-5 Level of Personality Functioning Scale: The LPFS Brief Form (LPFS-BF).

Personality Disorders: Theory, Research, and Treatment, 7(2), 192–197.

https://doi.org/10.1037/per0000159

Hutsebaut, J., Kamphuis, J. H., Feenstra, D. J., Weekers, L. C., & Saeger, H. de (2017).

Assessing DSM-5-oriented level of personality functioning: Development and

psychometric evaluation of the Semi-Structured Interview for Personality Functioning

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 48

DSM-5 (STiP-5.1). Personality Disorders: Theory, Research, and Treatment, 8(1), 94–

101. https://doi.org/10.1037/per0000197

Hutsebaut, J., Weekers, L. C., Tuin, N., Apeldoorn, J. S. P., & Bulten, E. (2021). Assessment

of ICD-11 personality disorder severity in forensic patients using the Semi-structured

Interview for Personality Functioning DSM-5 (STiP-5.1): Preliminary findings. Frontiers

in Psychiatry, 12, 617702. https://doi.org/10.3389/fpsyt.2021.617702

Jauk, E., & Ehrenthal, J. C. (2021). Self-reported levels of personality functioning from the

Operationalized Psychodynamic Diagnosis (OPD) system and emotional intelligence likely

assess the same latent construct. Journal of Personality Assessment, 103(3), 365–379.

https://doi.org/10.1080/00223891.2020.1775089

Kampe, L., Zimmermann, J., Bender, D., Caligor, E., Borowski, A.‑L., Ehrenthal, J. C.,

Benecke, C., & Hörz-Sagstetter, S. (2018). Comparison of the Structured DSM-5 Clinical

Interview for the Level of Personality Functioning Scale with the Structured Interview of

Personality Organization. Journal of Personality Assessment, 100(6), 642–649.

https://doi.org/10.1080/00223891.2018.1489257

Kamphuis, J. H., Noordhof, A., & Hopwood, C. J. (2021). When and how assessment matters:

An update on the Treatment Utility of Clinical Assessment (TUCA). Psychological

Assessment, 33(2), 122–132. https://doi.org/10.1037/pas0000966

Karukivi, M., Vahlberg, T., Horjamo, K., Nevalainen, M., & Korkeila, J. (2017). Clinical

importance of personality difficulties: Diagnostically sub-threshold personality disorders.

BMC Psychiatry, 17(1), 16. https://doi.org/10.1186/s12888-017-1200-y

Keeley, J. W., Reed, G. M., Roberts, M. C., Evans, S. C., Medina-Mora, M. E., Robles, R.,

Rebello, T., Sharan, P., Gureje, O., First, M. B., Andrews, H. F., Ayuso-Mateos, J. L [José

Luís], Gaebel, W., Zielasek, J., & Saxena, S. (2016). Developing a science of clinical

utility in diagnostic classification systems field study strategies for ICD-11 mental and
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 49

behavioral disorders. American Psychologist, 71(1), 3–16.

https://doi.org/10.1037/a0039972

Kernberg, O. F. (1984). Severe personality disorders. Yale University Press.

Kim, Y.‑R., Blashfield, R., Tyrer, P., Hwang, S.‑T., & Lee, H.‑S. (2014). Field trial of a

putative research algorithm for diagnosing ICD-11 personality disorders in psychiatric

patients: 1. Severity of personality disturbance. Personality and Mental Health, 8(1), 67–

78. https://doi.org/10.1002/pmh.1248

Konjusha, A., Hopwood, C. J., Price, A. L., Masuhr, O., & Zimmermann, J. (2021).

Investigating the transdiagnostic value of subjective emptiness. Journal of Personality

Disorders, 35(5), 788–800. https://doi.org/10.1521/pedi_2021_35_510

Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., & Skodol, A. E. (2012). Initial

construction of a maladaptive personality trait model and inventory for DSM-5.

Psychological Medicine, 42(09), 1879–1890. https://doi.org/10.1017/S0033291711002674

Krueger, R. F., Skodol, A. E., Livesley, W. J., Shrout, P. E., & Huang, Y. (2007).

Synthesizing dimensional and categorical approaches to personality disorders: refining the

research agenda for DSM-V Axis II. International Journal of Methods in Psychiatric

Research, 16(S1), S65-S73. https://doi.org/10.1002/mpr.212

Leclerc, P., Savard, C., Vachon, D. D., Faucher, J., Payant, M., Lampron, M., Tremblay, M.,

& Gamache, D. (2021). Analysis of the interaction between personality dysfunction and

traits in the statistical prediction of physical aggression: Results from outpatient and

community samples. Personality and Mental Health. Advance online publication.

https://doi.org/10.1002/pmh.1522

Leising, D., Krause, S., Köhler, D., Hinsen, K., & Clifton, A. (2011). Assessing interpersonal

functioning: Views from within and without. Journal of Research in Personality, 45(6),

631–641. https://doi.org/10.1016/j.jrp.2011.08.011
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 50

Leising, D., Rogers, K., & Ostner, J. (2009). The undisordered personality: Normative

assumptions underlying personality disorder diagnoses. Review of General Psychology,

13(3), 230–241. https://doi.org/10.1037/a0017139

Leising, D., Scherbaum, S., Packmohr, P., & Zimmermann, J. (2018). Substance and

evaluation in personality disorder diagnoses. Journal of Personality Disorders, 32(6), 766–

783. https://doi.org/10.1521/pedi_2017_31_324

Leising, D., Vogel, D., Waller, V., & Zimmermann, J. (2021). Correlations between person-

descriptive items are predictable from the product of their mid-point-centered social

desirability values. European Journal of Personality, 35(5), 667–689.

https://doi.org/10.1177/0890207020962331

Leising, D., & Zimmermann, J. (2011). An integrative conceptual framework for assessing

personality and personality pathology. Review of General Psychology, 15(4), 317–330.

https://doi.org/10.1037/a0025070

Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M.,

Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing

measurement-based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324–

335. https://doi.org/10.1001/jamapsychiatry.2018.3329

Liggett, J., Carmichael, K. L. C., Smith, A., & Sellbom, M. (2017). Validation of self-report

impairment measures for Section III obsessive-compulsive and avoidant personality

disorders. Journal of Personality Assessment, 99(1), 1–14.

https://doi.org/10.1080/00223891.2016.1185613

Liggett, J., & Sellbom, M. (2018). Examining the DSM-5 alternative model of personality

disorders operationalization of obsessive-compulsive personality disorder in a mental

health sample. Personality Disorders: Theory, Research, and Treatment, 9(5), 397–407.

https://doi.org/10.1037/per0000285
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 51

Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: Pdm-2

(Second edition). The Guilford Press.

Livesley, W. J. (1998). Suggestions for a framework for an empirically based classification of

personality disorder. Canadian Journal of Psychiatry/Revue Canadienne De Psychiatrie,

43(2), 137–147.

Livesley, W. J. (2006). General Assessment of Personality Disorder (GAPD). Department of

Psychiatry, University of British Columbia.

Luyten, P., & Blatt, S. J. (2013). Interpersonal relatedness and self-definition in normal and

disrupted personality development: Retrospect and prospect. American Psychologist,

68(3), 172–183. https://doi.org/10.1037/a0032243

Markon, K. E., Chmielewski, M., & Miller, C. J. (2011). The reliability and validity of

discrete and continuous measures of psychopathology: A quantitative review.

Psychological Bulletin, 137(5), 856–879. https://doi.org/10.1037/a0023678

McCabe, G. A., Oltmanns, J. R., & Widiger, T. A. (2021a). Criterion A scales: Convergent,

discriminant, and structural relationships. Assessment, 28(3), 813–828.

https://doi.org/10.1177/1073191120947160

McCabe, G. A., Oltmanns, J. R., & Widiger, T. A. (2021b). The general factors of personality

disorder, psychopathology, and personality. Journal of Personality Disorders. Advance

online publication. https://doi.org/10.1521/pedi_2021_35_530

McCabe, G. A., & Widiger, T. A. (2020). Discriminant validity of the alternative model of

personality disorder. Psychological Assessment, 32(12), 1158–1171.

https://doi.org/10.1037/pas0000955

Meehan, K. B., Siefert, C., Sexton, J., & Huprich, S. K. (2019). Expanding the role of levels

of personality functioning in personality disorder taxonomy: Commentary on “Criterion A

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 52

of the AMPD in HiTOP”. Journal of Personality Assessment, 101(4), 367–373.

https://doi.org/10.1080/00223891.2018.1551228

Meisner, M. W., Bach, B., Lenzenweger, M. F [Mark F.], Møller, L., Haahr, U. H.,

Petersen, L. S., Kongerslev, M. T., & Simonsen, E. (2021). Reconceptualization of

borderline conditions through the lens of the alternative model of personality disorders.

Personality Disorders: Theory, Research, and Treatment. Advance online publication.

https://doi.org/10.1037/per0000502

Meyer, B., & Pilkonis, P. A. (2005). An attachment model of personality disorders. In M. F.

Lenzenweger & J. F. Clarkin (Eds.), Major Theories of Personality Disorder (2nd ed.).

Guilford Press.

Milinkovic, M. S., & Tiliopoulos, N. (2020). A systematic review of the clinical utility of the

DSM-5 section III alternative model of personality disorder. Personality Disorders:

Theory, Research, and Treatment, 11(6), 377–397. https://doi.org/10.1037/per0000408

Møller, L., Meisner, M. W., Søgaard, U., Elklit, A., & Simonsen, E. (2021). Assessment of

personality functioning in ICD-11 posttraumatic stress disorder and complex posttraumatic

stress disorder. Personality Disorders: Theory, Research, and Treatment, 12(5), 466–474.

https://doi.org/10.1037/per0000491

Morey, L. C. (2017). Development and initial evaluation of a self-report form of the DSM-5

Level of Personality Functioning Scale. Psychological Assessment, 29(10), 1302–1308.

https://doi.org/10.1037/pas0000450

Morey, L. C. (2018). Application of the DSM-5 Level of Personality Functioning Scale by lay

raters. Journal of Personality Disorders, 32(5), 709–720.

https://doi.org/10.1521/pedi_2017_31_305
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 53

Morey, L. C. (2019). Interdiagnostician reliability of the DSM-5 Section II and Section III

Alternative Model criteria for borderline personality disorder. Journal of Personality

Disorders, 33(6), 721-S18. https://doi.org/10.1521/pedi_2019_33_362

Morey, L. C., & Bender, D. S. (2021). Articulating a core dimension of personality pathology.

In A. E. Skodol & J. M. Oldham (Eds.), The American Psychiatric Association Publishing

Textbook of Personality Disorders (3rd ed., pp. 47–64). American Psychiatric Publishing.

Morey, L. C., Bender, D. S., & Skodol, A. E. (2013). Validating the proposed Diagnostic and

Statistical Manual of Mental Disorders, 5th edition, severity indicator for personality

disorder. Journal of Nervous and Mental Disease, 201(9), 729–735.

https://doi.org/10.1097/NMD.0b013e3182a20ea8

Morey, L. C., Berghuis, H., Bender, D. S., Verheul, R., Krueger, R. F., & Skodol, A. E.

(2011). Toward a model for assessing level of personality functioning in DSM–5 Part II:

Empirical articulation of a core dimension of personality pathology. Journal of Personality

Assessment, 93(4), 347–353. https://doi.org/10.1080/00223891.2011.577853

Morey, L. C., Good, E. W., & Hopwood, C. J. (2020). Global personality dysfunction and the

relationship of pathological and normal trait domains in the DSM-5 alternative model for

personality disorders. Journal of Personality. Advance online publication.

https://doi.org/10.1111/jopy.12560

Morey, L. C., Skodol, A. E., & Oldham, J. M. (2014). Clinician judgments of clinical utility:

A comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5

personality disorders. Journal of Abnormal Psychology, 123(2), 398–405.

https://doi.org/10.1037/a0036481

Moshagen, M. (2012). The model size effect in SEM: Inflated goodness-of-fit statistics are

due to the size of the covariance matrix. Structural Equation Modeling: A

Multidisciplinary Journal, 19(1), 86–98. https://doi.org/10.1080/10705511.2012.634724

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 54

Mulay, A. L., Cain, N. M., Waugh, M. H., Hopwood, C. J., Adler, J. M., Garcia, D. J.,

Kurtz, J. E., Lenger, K. A., & Skadberg, R. (2018). Personality constructs and paradigms

in the Alternative DSM-5 Model of Personality Disorder. Journal of Personality

Assessment, 100(6), 593–602. https://doi.org/10.1080/00223891.2018.1477787

Mulder, R., & Tyrer, P. (2019). Diagnosis and classification of personality disorders: Novel

approaches. Current Opinion in Psychiatry, 32(1), 27–31.

https://doi.org/10.1097/YCO.0000000000000461

Müller, S [Sascha], Wendt, L. P., Spitzer, C., Masuhr, O., Back, S. N., & Zimmermann, J.

(2021). A critical evaluation of the Reflective Functioning Questionnaire (RFQ). Journal

of Personality Assessment. Advance online publication.

https://doi.org/10.1080/00223891.2021.1981346

Müller, S [Sascha], Wendt, L. P., & Zimmermann, J. (2021). Development and validation of

the Certainty About Mental States Questionnaire (CAMSQ): A self-report measure of

mentalizing oneself and others. Assessment. Advance online publication.

https://doi.org/10.1177/10731911211061280

Mullins-Sweatt, S. N., & Widiger, T. A. (2009). Clinical utility and DSM-V. Psychological

Assessment, 21(3), 302–312. https://doi.org/10.1037/a0016607

Munro, O. E., & Sellbom, M. (2020). Elucidating the relationship between borderline

personality disorder and intimate partner violence. Personality and Mental Health, 14(3),

284–303. https://doi.org/10.1002/pmh.1480

Nelson, S. M., Huprich, S. K., Meehan, K. B., Siefert, C., Haggerty, G., Sexton, J.,

Dauphin, V. B., Macaluso, M., Zackula, R., Baade, L., & Jackson, J. (2018). Convergent

and discriminant validity and utility of the DSM-5 Levels of Personality Functioning

Questionnaire (DLOPFQ): Associations with medical health care provider ratings and
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 55

measures of physical health. Journal of Personality Assessment, 100(6), 671–679.

https://doi.org/10.1080/00223891.2018.1492415

Nelson, S. M., Huprich, S. K., Shankar, S., Sohnleitner, A., & Paggeot, A. V. (2017). A

quantitative and qualitative evaluation of trainee opinions of four methods of personality

disorder diagnosis. Personality Disorders: Theory, Research, and Treatment, 8(3), 217–

227. https://doi.org/10.1037/per0000227

Ohse, L., Zimmermann, J., Kerber, A., Kampe, L., Mohr, J., Kendlbacher, J., Busch, O.,

Rentrop, M., & Hörz-Sagstetter, S. (2021). Reliability, structure and validity of the

Structured Clinical Interview for the Alternative DSM-5 Model for Personality Disorders –

Module I (SCID-5-AMPD-I). Manuscript Submitted for Publication.

Olajide, K., Munjiza, J., Moran, P., O’Connell, L., Newton-Howes, G., Bassett, P.,

Akintomide, G., Ng, N., Tyrer, P., Mulder, R., & Crawford, M. J. (2018). Development

and psychometric properties of the Standardized Assessment of Severity of Personality

Disorder (SASPD). Journal of Personality Disorders, 32(1), 44–56.

https://doi.org/10.1521/pedi_2017_31_285

Olderbak, S., & Wilhelm, O. (2020). Overarching principles for the organization of

socioemotional constructs. Current Directions in Psychological Science, 29(1), 63–70.

https://doi.org/10.1177/0963721419884317

Oltmanns, J. R., & Widiger, T. A. (2019). Evaluating the assessment of the ICD-11

personality disorder diagnostic system. Psychological Assessment, 31(5), 674–684.

https://doi.org/10.1037/pas0000693

OPD Task Force. (2008). Operationalized Psychodynamic Diagnosis OPD–2: Manual of

diagnosis and treatment planning. Hogrefe & Huber.

Paap, M. C. S., Heltne, A., Pedersen, G., Germans Selvik, S., Frans, N., Wilberg, T., &

Hummelen, B. (2021). More is more: Evidence for the incremental value of the SCID-
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 56

II/SCID-5-PD specific factors over and above a general personality disorder factor.

Personality Disorders: Theory, Research, and Treatment. Advance online publication.

https://doi.org/10.1037/per0000426

Parker, G., Both, L., Olley, A., Hadzi-Pavlovic, D., Irvine, P., & Jacobs, G. (2002). Defining

disordered personality functioning. Journal of Personality Disorders, 16(6), 503–522.

https://doi.org/10.1521/pedi.16.6.503.22139

Parker, G., Hadzi-Pavlovic, D., Both, L., Kumar, S., Wilhelm, K., & Olley, A. (2004).

Measuring disordered personality functioning: To love and to work reprised. Acta

Psychiatrica Scandinavica, 110(3), 230–239. https://doi.org/10.1111/j.1600-

0447.2004.00312.x

Persson, B. N., & Lilienfeld, S. O. (2019). Social status as one key indicator of successful

psychopathy: An initial empirical investigation. Personality and Individual Differences,

141, 209–217. https://doi.org/10.1016/j.paid.2019.01.020

Peter, L.‑J., Schindler, S., Sander, C., Schmidt, S., Muehlan, H., McLaren, T., Tomczyk, S.,

Speerforck, S., & Schomerus, G. (2021). Continuum beliefs and mental illness stigma: A

systematic review and meta-analysis of correlation and intervention studies. Psychological

Medicine, 51(5), 716–726. https://doi.org/10.1017/S0033291721000854

Pincus, A. L. (2018). An interpersonal perspective on Criterion A of the DSM-5 Alternative

Model for Personality Disorders. Current Opinion in Psychology, 21, 11–17.

https://doi.org/10.1016/j.copsyc.2017.08.035

Pincus, A. L., Cain, N. M., & Halberstadt, A. L. (2020). Importance of self and other in

defining personality pathology. Psychopathology, 53(3-4), 133–140.

https://doi.org/10.1159/000506313
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 57

Pincus, A. L., Dowgwillo, E. A., & Greenberg, L. S. (2016). Three cases of narcissistic

personality disorder through the lens of the DSM-5 alternative model for personality

disorders. Practice Innovations, 1(3), 164–177. https://doi.org/10.1037/pri0000025

Preti, E., Di Pierro, R., Costantini, G., Benzi, I. M. A., Panfilis, C. de, & Madeddu, F. (2018).

Using the Structured Interview of Personality Organization for DSM-5 Level of

Personality Functioning rating performed by inexperienced raters. Journal of Personality

Assessment, 100(6), 621–629. https://doi.org/10.1080/00223891.2018.1448985

Prevolnik Rupel, V., Jagger, B., Fialho, L. S., Chadderton, L.‑M., Gintner, T., Arntz, A.,

Baltzersen, Å.‑L., Blazdell, J., van Busschbach, J., Cencelli, M., Chanen, A., Delvaux, C.,

van Gorp, F., Langford, L., McKenna, B., Moran, P., Pacheco, K., Sharp, C.,

Wang, W., . . . Crawford, M. J. (2021). Standard set of patient-reported outcomes for

personality disorder. Quality of Life Research. Advance online publication.

https://doi.org/10.1007/s11136-021-02870-w

Quilty, L. C., Bagby, R. M., Krueger, R. F., & Pollock, B. G. (2021). Validation of DSM-5

clinician-rated measures of personality pathology. Psychological Assessment, 33(1), 84–

89. https://doi.org/10.1037/pas0000960

Reed, G. M., First, M. B., Kogan, C. S., Hyman, S. E., Gureje, O., Gaebel, W., Maj, M.,

Stein, D. J., Maercker, A., Tyrer, P., Claudino, A., Garralda, E., Salvador-Carulla, L.,

Ray, R., Saunders, J. B., Dua, T., Poznyak, V., Medina-Mora, M. E., Pike, K. M., . . .

Saxena, S. (2019). Innovations and changes in the ICD-11 classification of mental,

behavioural and neurodevelopmental disorders. World Psychiatry, 18(1), 3–19.

https://doi.org/10.1002/wps.20611

Ringwald, W. R., Beeney, J. E., Pilkonis, P. A., & Wright, A. G. C. (2019). Comparing

hierarchical models of personality pathology. Journal of Research in Personality, 81, 98–

107. https://doi.org/10.1016/j.jrp.2019.05.011
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 58

Ringwald, W. R., Hopwood, C. J., Pilkonis, P. A., & Wright, A. G. C. (2021). Dynamic

features of affect and interpersonal behavior in relation to general and specific personality

pathology. Personality Disorders: Theory, Research, and Treatment, 12(4), 365–376.

https://doi.org/10.1037/per0000469

Rishede, M. Z., Juul, S., Bo, S., Gondan, M., Bjerrum Møeller, S., & Simonsen, S. (2021).

Personality functioning and mentalizing in patients with subthreshold or diagnosed

borderline personality disorder: Implications for ICD-11. Frontiers in Psychiatry, 12,

634332. https://doi.org/10.3389/fpsyt.2021.634332

Roberts, J. S., Donoghue, J. R., & Laughlin, J. E. (2000). A general item response theory

model for unfolding unidimensional polytomous responses. Applied Psychological

Measurement, 24(1), 3–32. https://doi.org/10.1177/01466216000241001

Roche, M. J. (2018). Examining the alternative model for personality disorder in daily life:

Evidence for incremental validity. Personality Disorders: Theory, Research, and

Treatment, 9(6), 574–583. https://doi.org/10.1037/per0000295

Roche, M. J., Jacobson, N. C., & Phillips, J. J. (2018). Expanding the validity of the Level of

Personality Functioning Scale observer report and self-report versions across

psychodynamic and interpersonal paradigms. Journal of Personality Assessment, 100(6),

571–580. https://doi.org/10.1080/00223891.2018.1475394

Roche, M. J., Jacobson, N. C., & Pincus, A. L. (2016). Using repeated daily assessments to

uncover oscillating patterns and temporally-dynamic triggers in structures of

psychopathology: Applications to the DSM-5 alternative model of personality disorders.

Journal of Abnormal Psychology, 125(8), 1090–1102. https://doi.org/10.1037/abn0000177

Roche, M. J., & Jaweed, S. (2021). Comparing measures of Criterion A to better understand

incremental validity in the Alternative Model of Personality Disorders. Assessment.

Advance online publication. https://doi.org/10.1177/10731911211059763

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 59

Ruchensky, J. R., Dowgwillo, E. A., Kelley, S. E., Massey, C., Slavin-Mulford, J.,

Richardson, L. A., Blais, M. A., & Stein, M. B. (2021). Exploring the Alternative Model

for Personality Disorders using SCORS-G ratings on Thematic Apperception Test

narratives. Journal of Personality Disorders. Advance online publication.

https://doi.org/10.1521/pedi_2021_35_535

Saulsman, L. M., & Page, A. C. (2004). The five-factor model and personality disorder

empirical literature: A meta-analytic review. Clinical Psychology Review, 23(8), 1055–

1085. https://doi.org/10.1016/j.cpr.2002.09.001

Schmeck, K., Schlüter-Müller, S., Foelsch, P. A., & Doering, S. (2013). The role of identity in

the DSM-5 classification of personality disorders. Child and Adolescent Psychiatry and

Mental Health, 7(1), 27. https://doi.org/10.1186/1753-2000-7-27

Sharp, C., & Wall, K. (2021). Dsm-5 Level of Personality Functioning: Refocusing

personality disorder on what it means to be human. Annual Review of Clinical Psychology,

17, 313–337. https://doi.org/10.1146/annurev-clinpsy-081219-105402

Sharp, C., Wright, A. G. C., Fowler, J. C., Frueh, B. C., Allen, J. G., Oldham, J., &

Clark, L. A. (2015). The structure of personality pathology: Both general (‘g’) and specific

(‘s’) factors? Journal of Abnormal Psychology, 124(2), 387–398.

https://doi.org/10.1037/abn0000033

Siefert, C. J., Sexton, J., Meehan, K., Nelson, S., Haggerty, G., Dauphin, B., & Huprich, S.

(2020). Development of a short form for the DSM-5 Levels of Personality Functioning

Questionnaire. Journal of Personality Assessment, 102(4), 516–526.

https://doi.org/10.1080/00223891.2019.1594842

Sinnaeve, R., Vaessen, T., van Diest, I., Myin-Germeys, I., van den Bosch, L. M. C.,

Vrieze, E., Kamphuis, J. H., & Claes, S. (2021). Investigating the stress-related

fluctuations of level of personality functioning: A critical review and agenda for future
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 60

research. Clinical Psychology & Psychotherapy, 28(5), 1181–1193.

https://doi.org/10.1002/cpp.2566

Skodol, A. E. (2012). Personality disorders in DSM-5. Annual Review of Clinical Psychology,

8(1), 317–344. https://doi.org/10.1146/annurev-clinpsy-032511-143131

Skodol, A. E., Morey, L. C., Bender, D. S., & Oldham, J. M. (2015). The Alternative DSM-5

Model for Personality Disorders: A clinical application. American Journal of Psychiatry,

172(7), 606–613. https://doi.org/10.1176/appi.ajp.2015.14101220

Sleep, C. E., Lynam, D. R., & Miller, J. D. (2021). Personality impairment in the DSM-5 and

ICD-11: Current standing and limitations. Current Opinion in Psychiatry, 34(1), 39–43.

https://doi.org/10.1097/YCO.0000000000000657

Sleep, C. E., Lynam, D. R., Widiger, T. A., Crowe, M. L., & Miller, J. D. (2019). An

evaluation of DSM-5 Section III personality disorder Criterion A (impairment) in

accounting for psychopathology. Psychological Assessment, 31(10), 1181–1191.

https://doi.org/10.1037/pas0000620

Sleep, C. E., Weiss, B., Lynam, D. R., & Miller, J. D. (2020). The DSM-5 Section III

personality disorder Criterion A in relation to both pathological and general personality

traits. Personality Disorders: Theory, Research, and Treatment, 11(3), 202–212.

https://doi.org/10.1037/per0000383

Somma, A., Borroni, S., Gialdi, G., Carlotta, D., Emanuela Giarolli, L., Barranca, M.,

Cerioli, C., Franzoni, C., Masci, E., Manini, R., Luca Busso, S., Ruotolo, G.,

Krueger, R. F., Markon, K. E., & Fossati, A. (2020). The inter-rater reliability and validity

of the Italian translation of the Structured Clinical Interview for DSM-5 Alternative Model

for Personality Disorders Module I and Module II: A preliminary report on consecutively

admitted psychotherapy outpatients. Journal of Personality Disorders, 34(Supplement C),

95–123. https://doi.org/10.1521/pedi_2020_34_511
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 61

Spitzer, C., Müller, S [Steffen], Kerber, A., Hutsebaut, J., Brähler, E., & Zimmermann, J.

(2021). Die deutsche Version der Level of Personality Functioning Scale-Brief Form 2.0

(LPFS-BF): Faktorenstruktur, konvergente Validität und Normwerte in der

Allgemeinbevölkerung [The German version of the Level of Personality Functioning

Scale-Brief Form 2.0 (LPFS-BF): Latent structure, convergent validity and norm values in

the general population]. Psychotherapie, Psychosomatik, medizinische Psychologie, 71(7),

284–293. https://doi.org/10.1055/a-1343-2396

Stone, L. E., Segal, D. L., & Noel, O. R. (2020). Psychometric evaluation of the Levels of

Personality Functioning Scale-Brief Form 2.0 among older adults. Personality Disorders:

Theory, Research, and Treatment. Advance online publication.

https://doi.org/10.1037/per0000413

Stover, J. B., Liporace, M. F., & Castro Solano, A. (2020). Personality functioning scale: A

scale to assess DSM-5’s Criterion A personality disorders. Interpersona: An International

Journal on Personal Relationships, 14(1), 40–53. https://doi.org/10.5964/ijpr.v14i1.3925

Stricker, J., & Pietrowsky, R. (2021). Incremental validity of the ICD-11 personality disorder

model for explaining psychological distress. Personality Disorders: Theory, Research, and

Treatment. Advance online publication. https://doi.org/10.1037/per0000489

Svrakic, D. M., Whitehead, C., Przybeck, T. R., & Cloninger, C. R. (1993). Differential

diagnosis of personality disorders by the seven-factor model of temperament and character.

Archives of General Psychiatry, 50(12), 991–999.

Thompson, K. N., Jackson, H., Cavelti, M., Betts, J., McCutcheon, L., Jovev, M., &

Chanen, A. M. (2019). The clinical significance of subthreshold borderline personality

disorder features in outpatient youth. Journal of Personality Disorders, 33(1), 71–81.

https://doi.org/10.1521/pedi_2018_32_330
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 62

Thylstrup, B., Simonsen, S., Nemery, C., Simonsen, E., Noll, J. F., Myatt, M. W., &

Hesse, M. (2016). Assessment of personality-related levels of functioning: A pilot study of

clinical assessment of the DSM-5 level of personality functioning based on a semi-

structured interview. BMC Psychiatry, 16, 298. https://doi.org/10.1186/s12888-016-1011-6

Traynor, J. M., Wrege, J. S., Walter, M., & Ruocco, A. C. (2021). Dimensional personality

impairment is associated with disruptions in intrinsic intralimbic functional connectivity.

Psychological Medicine. Advance online publication.

https://doi.org/10.1017/S0033291721002865

Turkheimer, E., Ford, D. C., & Oltmanns, T. F. (2008). Regional analysis of self-reported

personality disorder criteria. Journal of Personality, 76(6), 1587–1622.

https://doi.org/10.1111/j.1467-6494.2008.00532.x

Tyrer, P., Crawford, M. J., Sanatinia, R., Tyrer, H., Cooper, S., Muller-Pollard, C.,

Christodoulou, P., Zauter-Tutt, M., Miloseska-Reid, K., Loebenberg, G., Guo, B.,

Yang, M., Wang, D., & Weich, S. (2014). Preliminary studies of the ICD-11 classification

of personality disorder in practice. Personality and Mental Health, 8(4), 254–263.

https://doi.org/10.1002/pmh.1275

Tyrer, P., & Johnson, T. (1996). Establishing the severity of personality disorder. American

Journal of Psychiatry, 153(12), 1593–1597.

Tyrer, P., Reed, G. M., & Crawford, M. J. (2015). Classification, assessment, prevalence, and

effect of personality disorder. The Lancet, 385(9969), 717–726.

https://doi.org/10.1016/S0140-6736(14)61995-4

Verheul, R., Andrea, H., Berghout, C. C., Dolan, C., Busschbach, J. J. V., van der

Kroft, P. J. A., Bateman, A. W., & Fonagy, P. (2008). Severity Indices of Personality

Problems (SIPP-118): Development, factor structure, reliability, and validity.

Psychological Assessment, 20(1), 23–34. https://doi.org/10.1037/1040-3590.20.1.23

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 63

Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between biological

facts and social values. American Psychologist, 47(3), 373–388.

https://doi.org/10.1037/0003-066X.47.3.373

Waugh, M. H., McClain, C. M., Mariotti, E. C., Mulay, A. L., DeVore, E. N., Lenger, K. A.,

Russell, A. N., Florimbio, A. R., Lewis, K. C., Ridenour, J. M., & Beevers, L. G. (2021).

Comparative content analysis of self-report scales for level of personality functioning.

Journal of Personality Assessment, 103(2), 161–173.

https://doi.org/10.1080/00223891.2019.1705464

Weekers, L. C., Hutsebaut, J., Bach, B., & Kamphuis, J. H. (2020). Scripting the DSM-5

Alternative Model for Personality Disorders assessment procedure: A clinically feasible

multi-informant multi-method approach. Personality and Mental Health, 14(3), 304–318.

https://doi.org/10.1002/pmh.1481

Weekers, L. C., Hutsebaut, J., & Kamphuis, J. H. (2019). The Level of Personality

Functioning Scale-Brief Form 2.0: Update of a brief instrument for assessing level of

personality functioning. Personality and Mental Health, 13(1), 3–14.

https://doi.org/10.1002/pmh.1434

Weekers, L. C., Hutsebaut, J., & Kamphuis, J. H. (2021). Client and clinical utility of the

assessment of personality disorders. Journal of Nervous and Mental Disease, 209(11),

846–850. https://doi.org/10.1097/NMD.0000000000001398

Weekers, L. C., Verhoeff, S. C. E., Kamphuis, J. H., & Hutsebaut, J. (2021). Assessing

Criterion A in adolescents using the Semistructured Interview for Personality Functioning

DSM-5. Personality Disorders: Theory, Research, and Treatment, 12(4), 312–319.

https://doi.org/10.1037/per0000454
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 64

Westen, D., Barends, A., Leigh, M., Mendel, M., & Silbert, D. (1990). Social Cognition and

Object Relations Scale (SCORS): Manual for coding interview data: Unpublished

manuscript. University of Michigan.

Westen, D., Gabbard, G. O., & Blagov, P. S. (2006). Back to the future: Personality structure

as a context for psychopathology. In R. F. Krueger & J. L. Tackett (Eds.), Personality and

psychopathology (pp. 335–384). Guilford Press.

Widiger, T. A., Bach, B., Chmielewski, M., Clark, L. A., DeYoung, C., Hopwood, C. J.,

Kotov, R., Krueger, R. F., Miller, J. D., Morey, L. C., Mullins-Sweatt, S. N., Patrick, C. J.,

Pincus, A. L., Samuel, D. B., Sellbom, M., South, S. C., Tackett, J. L., Watson, D.,

Waugh, M. H., . . . Thomas, K. M. (2019). Criterion A of the AMPD in HiTOP. Journal of

Personality Assessment, 101(4), 345–355. https://doi.org/10.1080/00223891.2018.1465431

Widiger, T. A., & Mullins-Sweatt, S. N. (2009). Five-factor model of personality disorder: A

proposal for DSM-V. Annual Review of Clinical Psychology, 5(1), 197–220.

https://doi.org/10.1146/annurev.clinpsy.032408.153542

Widiger, T. A., & Trull, T. J. (2007). Plate tectonics in the classification of personality

disorder: Shifting to a dimensional model. American Psychologist, 62(2), 71–83.

https://doi.org/10.1037/0003-066X.62.2.71

Williams, T. F., Scalco, M. D., & Simms, L. J. (2018). The construct validity of general and

specific dimensions of personality pathology. Psychological Medicine, 48(5), 834–848.

https://doi.org/10.1017/S0033291717002227

Wright, A. G., Hopwood, C. J., Skodol, A. E., & Morey, L. C. (2016). Longitudinal validation

of general and specific structural features of personality pathology. Journal of Abnormal

Psychology, 125(8), 1120–1134. https://doi.org/10.1037/abn0000165

Wygant, D. B., Sellbom, M., Sleep, C. E., Wall, T. D., Applegate, K. C., Krueger, R. F., &

Patrick, C. J. (2016). Examining the DSM-5 alternative personality disorder model

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 65

operationalization of antisocial personality disorder and psychopathy in a male correctional

sample. Personality Disorders: Theory, Research, and Treatment, 7(3), 229–239.

https://doi.org/10.1037/per0000179

Yalch, M. M. (2020). Psychodynamic underpinnings of the DSM–5 Alternative Model for

Personality Disorder. Psychoanalytic Psychology, 37(3), 219–231.

https://doi.org/10.1037/pap0000262

Yang, M., Coid, J., & Tyrer, P. (2010). Personality pathology recorded by severity: national

survey. British Journal of Psychiatry, 197(3), 193–199.

https://doi.org/10.1192/bjp.bp.110.078956

Zettl, M., Volkert, J., Vögele, C., Herpertz, S. C., Kubera, K. M., & Taubner, S. (2020).

Mentalization and Criterion A of the Alternative Model for Personality Disorders: Results

from a clinical and nonclinical sample. Personality Disorders: Theory, Research, and

Treatment, 11(3), 191–201. https://doi.org/10.1037/per0000356

Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM-IV

personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162(10),

1911–1918. https://doi.org/10.1176/appi.ajp.162.10.1911

Zimmermann, J., Benecke, C., Bender, D. S., Skodol, A. E., Schauenburg, H., Cierpka, M., &

Leising, D. (2014). Assessing DSM-5 Level of Personality Functioning from videotaped

clinical interviews: A pilot study with untrained and clinically inexperienced students.

Journal of Personality Assessment, 96(4), 397–409.

https://doi.org/10.1080/00223891.2013.852563

Zimmermann, J., Böhnke, J. R., Eschstruth, R., Mathews, A., Wenzel, K., & Leising, D.

(2015). The latent structure of personality functioning: Investigating criterion A from the

alternative model for personality disorders in DSM-5. Journal of Abnormal Psychology,

124(3), 532–548. https://doi.org/10.1037/abn0000059

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 66

Zimmermann, J., Ehrenthal, J. C., Cierpka, M., Schauenburg, H., Doering, S., & Benecke, C.

(2012). Assessing the level of structural integration using Operationalized Psychodynamic

Diagnosis (OPD): Implications for DSM–5. Journal of Personality Assessment, 94(5),

522–532. https://doi.org/10.1080/00223891.2012.700664

Zimmermann, J., Kerber, A., Rek, K., Hopwood, C. J., & Krueger, R. F. (2019). A brief but

comprehensive review of research on the Alternative DSM-5 Model for Personality

Disorders. Current Psychiatry Reports, 21(9), 92. https://doi.org/10.1007/s11920-019-

1079-z

Zimmermann, J., Müller, S [Steffen], Bach, B., Hutsebaut, J., Hummelen, B., & Fischer, F.

(2020). A common metric for self-reported severity of personality disorder.

Psychopathology, 53(3-4), 168–178. https://doi.org/10.1159/000507377

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 67

Table 1

Components and subcomponents of personality functioning according to Criterion A

Component Subcomponents

Identity Sense of self

Self-esteem and accurate self-perception
Emotional range and regulation

Self-direction Ability to pursue meaningful goals

Prosocial internal standards of behavior
Self-reflective functioning

Empathy Understanding others’ experiences and motivations

Tolerance of differing perspectives
Understanding effects of own behavior on others

Intimacy Depth and duration of connections

Desire and capacity for closeness
Mutuality of regard
Note. Adapted from DSM-5, p. 762.
Table 2

Measures for the assessment of personality functioning according to the LPFS

Measure Authors Original language and Method Items Scales

validated translations

Clinical Assessment of the Level of Thylstrup et al. (2016) Danish Structured Interview 4 1
Personality Functioning Scale
(CALF)

DSM-5 Levels of Personality Huprich et al. (2018); English Self-Report 23/132 4/8
Functioning Questionnaire Siefert et al. (2020)
(DLOPFQ)

Level of Personality Functioning Morey (2017) English Self-Report 80 4

Scale – Self-Report (LPFS-SR) German (Zimmermann et al.,
2020); Persian (Hemmati et
al., 2020)

Level of Personality Functioning Hutsebaut et al. (2016); Dutch Self-Report 12 2

Scale – Brief Form (LPFS-BF; Weekers et al. (2019) English (Stone et al., 2020);
LPFS-BF 2.0) Danish (Bach & Hutsebaut,
2018); German (Spitzer et al.,
2021); Czech (Heissler et al.,
2021)

Personality Functioning Scale (PFS) Stover et al. (2020) Spanish Self-Report 28 2

DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 69

Levels of Personality Functioning Goth et al. (2018) German Self-Report 97 4/8

Questionnaire for Adolescents from Turkish (Cosgun et al., 2021)
12 to 18 Years (LoPF-Q 12-18)

Self and Interpersonal Functioning Gamache et al. (2019) French Self-Report 24 1/4
Scale (SIFS)

Semi-Structured Interview for Hutsebaut et al. (2017) Dutch Structured Interview 12 1/4
Personality Functioning DSM–5 German (Zettl et al., 2020);
(STiP-5.1) Czech (Heissler et al., 2021)

Structured Clinical Interview for the Bender, Skodol, et al. English Structured Interview 12 1/4
Level of Personality Functioning (2018) German (Kampe et al., 2018);
Scale (SCID-AMPD Module I) Italian (Somma et al., 2020);
Norwegian (Buer Christensen
et al., 2018); Danish (Meisner
et al., 2021)
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 70

Table 3

Studies on the interrater reliability of the LPFS

Raters per Total

Sample Source Items Raters Targets ICC
target targets

Cruitt et al., (2019) Life story interviews 12 Students 3 Older adults 162 .56

Dereboy et al. (2018) Observations during patients’ 4 Psychiatrists and students 4 Patients 20 .67
stay at the ward

Di Pierro et al., STIPO 12 Students 2 Patients and healthy 12 .80#

(2020) controls

Few et al. (2012) SCID-II 4 Students 2 Patients 103 .48#

Garcia et al. (2018) Written case vignettes 4 Students 13 Patients 15 .81

Morey (2019) Written case vignettes 1 Mental health professionals 40 Patients 12 .50

Preti et al. (2018) STIPO 12 Students 10 Patients 10 .42

Roche & Jaweed Audiotaped brief personality 12 Students 5 Students 92 .52

(2021) interview

Roche et al. (2018), Self-written psychological life 12 Students 5 Students 70 .58

Sample 1 history

Roche et al. (2018), Self-written psychological life 12 Students 5 Students 85 .42

Sample 2a history
DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 71

Roche et al. (2018), Self-written psychological life 12 Students 5 Students 85 .36

Sample 2b history

Zimmermann et al OPD interview 12 Students 22 Patients 10 .51

(2014)

Buer Christensen et SCID-AMPD Module I 12 Clinicians and students 5 Patients 17 .96

al. (2018)

Hutsebaut et al. STiP-5.1 12 Psychologists 2 Patients* 40 .71

(2017)

Kampe et al. (2018) SCID-AMPD Module I 12 Psychologist and student 2 Patients 30 .93

Meisner et al. (2021) SCID-AMPD Module I 12 Psychologist and 3 Patients 15 .79+

psychiatrist

Møller et al. (2021) SCID-AMPD Module I 12 Clinicians 3 Patients 14 .62+

Ohse et al. (2021) SCID-AMPD Module I 12 Psychologists 4 Patients 15 .95

Somma et al. (2020) SCID-AMPD Module I 12 Clinical psychologists 2 Patients 88 .87

Thylstrup et al. CALF 4 Psychologists, medical 2 Patients* 30 .54

(2016) doctors, student

Zettl et al. (2020) STiP-5.1 12 Psychologists 2 Patients* 27 .77+

Note. OPD = Operationalized Psychodynamic Diagnosis. SCID-II = Structured Clinical Interview for DSM-IV Personality Disorders. STIPO =
Structured Interview of Personality Organization. ICC = Intraclass correlation coefficient for single raters. * We only included results from the
patient sample. # We subsequently computed these values by averaging the ICCs for LPFS component scores. + We subsequently corrected this
value to provide an ICC for single raters.
Table 4

Studies on the association between self- or other-reported impairments in personality

functioning and measures of related clinical constructs

Other-reports Self-reports

Presence/number of PD diagnoses/criteria Impairments in personality functioning

according to DSM-IV (Buer Christensen, and PD severity (Bach & Anderson,
Hummelen, et al., 2020; Cruitt et al., 2019; 2020; Brown & Sellbom, 2020;
Dereboy et al., 2018; Di Pierro et al., 2020; Few Gamache et al., 2019; Hemmati et al.,
et al., 2013; Hutsebaut et al., 2017; Morey et 2020; Hopwood et al., 2018; Hutsebaut
al., 2013; Preti et al., 2018; Zimmermann et al., et al., 2016; Jauk & Ehrenthal, 2021;
2014) Morey, 2017; Oltmanns & Widiger,
2019; Sleep et al., 2019; Sleep et al.,
Psychodynamic conceptualizations of
2020; Weekers et al., 2019)
personality dysfunction (Kampe et al., 2018;
Ohse et al., 2021; Preti et al., 2018; Ruchensky Borderline PD symptoms (Gamache et
et al., 2021; Zettl et al., 2020; Zimmermann et al., 2019; Goth et al., 2018; Rishede et
al., 2014) al., 2021)
Self-reported personality pathology (Cruitt et Low self-esteem (Gamache et al., 2019)
al., 2019; Hutsebaut et al., 2017; Quilty et al., Suicidality (Bach & Anderson, 2020;
2021) Roche & Jaweed, 2021)
Impairments in psychosocial functioning (Buer Subjective emptiness (Konjusha et al.,
Christensen, Eikenaes, et al., 2020; Morey et
2021)
al., 2013)
Impairments in mentalizing (Müller,
Complex posttraumatic stress disorder and Wendt, Spitzer, et al., 2021; Müller,
disturbances in self-organization (Møller et al., Wendt, & Zimmermann, 2021; Rishede
2021) et al., 2021)
Substance use history (Cruitt et al., 2019) Low emotional intelligence (Jauk &
Mental and physical health problems (Cruitt et Ehrenthal, 2021)
al., 2019) Narcissism and aggression (Gamache et
Social and relational maladjustment (Cruitt et al., 2019)
al., 2019) Psychopathy (Persson & Lilienfeld,
Symptom distress (Few et al., 2013; Hutsebaut 2019)
et al., 2017; Zettl et al., 2020) Intimate partner violence (Munro &
Sellbom, 2020)
Eating pathology (Biberdzic et al., 2021)
Childhood adversity (Back et al., 2020;
Gander et al., 2020)
Maternal bonding impairment (Fleck et
al., 2021)
Maladaptive schemas (Bach &
Anderson, 2020; Bach & Hutsebaut,
2018)
 DSM-5 LEVEL OF PERSONALITY FUNCTIONING SCALE 73

Immature defenses (Roche et al., 2018)

Insecure attachment (Gander et al., 2020;
Huprich et al., 2018; Roche et al., 2018)
Interpersonal dependency (Huprich et al.,
2018)
Interpersonal problems, sensitivities,
motives, and efficacies (Dowgwillo et
al., 2018; Hopwood et al., 2018; Roche
et al., 2018; Roche & Jaweed, 2021;
Stone et al., 2020)
Symptom distress and health problems
(Bach & Hutsebaut, 2018; Gamache et
al., 2019; Gamache, Savard, Lemieux, &
Berthelot, 2021; Hutsebaut et al., 2016;
Roche & Jaweed, 2021; Sleep et al.,
2019; Sleep et al., 2020; Stover et al.,
2020; Weekers et al., 2019)
Low well-being (Bach & Hutsebaut,
2018; Gamache et al., 2019; Huprich et
al., 2018; Nelson et al., 2018; Stover et
al., 2020)
Note. Other-reports include LPFS ratings from experts, laypersons, and informants, partly
based on structured clinical interviews. Self-reports include LPFS self-ratings or self-report
measures summarized in Table 2. Note that studies on the association between impairments in
personality functioning (Criterion A) and maladaptive personality traits (Criterion B) were
omitted.

View publication stats